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A L U M N i; B U L Ee t I 1^ 

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Wesfter 1997 
VoLUMEj^ Number 3 

Harvard Medical 



Between Clock and Bed, 
SeK-Portrait, 1940-1942 
Edvard Munch, 1863-1944 
Munch Museum, Oslo, 
Norway. Photo courtesy of 
Tatyana Robson. 

16 Easeful Death: From Keats to Kevorkian 

by Sissela Bok 

Pulls of the soul in the debates over 

suicide and euthanasia. 

21 Death on the Streets 

by James J. O^Connell 

When the fragile lifeline to the 

homeless fails. 

27 Risky and Nonrisky Acts 

by Sidney Wanzer 

The spectrum of physician 

assistance in dying. 

28 Planning for the End 

by Janet Walzer 

An interview with Linda Emanuel 
'84, the new vice president for 
ethics standards at the AMA. 

33 A Good Death 

by Howard M. Spiro 
Theologians, physicians and 
historians meet to reacquaint 
themselves with death. 

37 My Patients, My Self 

by Susan Block, J. Andrew Billings 

and Lynn Peterson 

Students learn from patients facing 


38 The Long Walk 

by Anne Hallward and Joshua Hauser 
41 The Last Lesson 
by Jennifer Furiti 


15 Ode to a Nightingale 

by John Keats 

25 Give Me a Doctor 

by W.H. Auden 


by George S. Bascom '52 

Good Night Willie Lee, I'll 

See You in the Morning 

by Alice Walker 

45 I Heard a Fly Buzz 

by Emily Dickinson 
The Ship Pounding 

by Donald Hall 


3 Letters 

4 Pulse 

New dean chosen, profile of entering 
class, bad mouse moms, publishing 
initiative lavmched, scholars in medi- 
cine honored, 150th anniversary of 
ether demo, genetically altered frog, 
Primary Care Day, anger and heart 

13 President's Report 

by Suzanne W. Fletcher 

50 Alumni Notes 


Alumnus Profile 

Donald Bickley 

46 How Denny-Brown Came to Harvard 

by Sid Shulman and Joel Vilensky 
A deal is struck with Winston 
Churchill for one of the 
world's foremost neurologists. 

55 In Memoriam 

Leonard W. Cronkhite Jr. 
Henry Swan II 

59 Death Notices 

Inside hmab 

Harvard Medical 

A L u M N 


My mother's last words to me were mouthed around an endotracheal 
tube: "Let me die. I want to die." It was no longer, however, a matter 
of choice for her. After a night of defibrillations and resuscitations, 
her heart was irreparable, and in the next few minutes her wish would 
come to pass. I stood there wanting to demand that the tube be taken 
out. Although the device obstructed any hope that she or I could 
have even a fragment of conversation, common sense and the 
courage to utter it failed me. Half believing the tube must have some 
further use, I reported correctly that my mother was in pain. An 
analgesic was quickly given; she fell asleep, and I watched a monitor 
record the syntax of her heart as it lapsed into electrical chatter and 

It was a swift death — barely 72 hours from first pain to last 
breath — not long enough for deliberations about the choice she 
expressed, the use of technology, the way it distorted a relationship at 
the last moment, the propriety of injecting something that might not 
only ease but speed her passing. 

Many years later I was asked to go to the bedside of a man dying 
somewhat more slowly in a Harvard teaching hospital. The task was 
to judge his competence. At least daily the treatment team came by to 
explore his views on resuscitation, and they found his responses to be 
inconsistent. I thought he was saying the same thing each time: "If I 
could go on living, I'd like to, but if the end is here, so be it." His 
sentiment was consistent but hard to operationalize. I suggested that 
the treatment team stop repeating their questions and bear some of 
the burden of the uncertainty and anxiety, instead of thrusting it all 
on the patient. The next day, as I walked by, a physician was leaning 
over the bed once again: "If you stop breathing, do you want us to 
put a tube in and breathe for you?" 

Even in this era of nonstop talk (and 80,000 retrievable World 
Wide Web items) on death and dying, physicians continue inade- 
quately prepared to negotiate a seemly truce with approaching death, 
according to the authors in this issue of HMAB. But at HMS there is a 
new generation of students being taught by the dying themselves, 
who may begin to change this state of affairs. 

William Ira Bennett ''68 


William Ira Bennett '68 


Ellen Barlow 

Associate Editor 

Janet Walzer 

Assistant Editor 

Sarah Jane Nelson 

Editorial Board 

Elissa A. Ely '88 
Melinda Fan '96 
Robert M. Goldwyn '56 
Joshua Hauser '95 
Paula A. Johnson '84 
Victoria McEvoy '75 
James J. O'Connell '82 
Gabriel Otterman '91 
Deborah Prothrow-Stith '79 
Guillermo C. Sanchez '49 
J. Gordon Scannell '40 
Eleanor Shore '55 
John D. Stoeckle '47 
Richard J. Wolfe 

Design Direction 

Sametz Blackstone Associates, Inc. 

Association Officers 

Suzanne Fletcher '66, president 
Robert S. Lawrence '64, president-elect i 
George E. Thibault '69, president-elect 2 
Roman W. DeSanctis '55, vice president 
David D. Oakes '68, secretary 
Arthur R. Kravitz '54, treasurer 


David P. Gilmour '66 
Laurie R. Green '76 
Katherine L. Griem '82 
Gerald T. Keursch '62 
Dana Leifer '85 
Alison G. May '91 
Sharon B. Murphy '69 
Gilbert S. Omenn '65 
John B. Stanbury '39 

Director of Alumni Relations 

Daniel D. Eederman '53 

Representative to the Harvard Alumni Association 

Chester d'Autremont '44 

ID Statement: 

The Harvard Medical Aluvini Bulletin is pubhshed 
quarterly at 2 5 Shattuck Street, Boston, MA 02 11 5 
© by the Harvard Medical Alumni Association. 
Telephone: (617) 432-1548. Email address: Third class postage 
paid at Boston, Massachusetts. Postmaster, send form 
3579 to 25 Shattuck Street, Boston, MA 02 11 5, 
ISSN 0191-7757. Printed in the U.S.A. 

Harvard Medical Alumni Bulletin 


stuff and Nonsense 

I was surprised to read in the Bulletin 
(Summer 1996) the magisterial state- 
ment by Dr. Andrew Weil that "we 
can never completely understand why 
people do or don't get better." 

If Dr. Weil was not misquoted, 
then I have to ask where he gets such 
ideas. It is not good enough to say, if 
indeed he says it, that there are many 
unsolved problems in medicine. This 
is of course correct, but there are 
many challenges that have been met. 
There is considerable hope that new 
solutions, including ones that do not 
ignore Koch's postulates, are on the 
way. If we are in a battle with the shift- 
ing immunologic defenses of bacteria, 
let us look carefully at this phenome- 
non to see if we can mobilize genetic 
and other mechanisms to counteract it. 
This and kindred evidence, if achieved, 
should explain, even for those as 
obtuse as Dr. Weil, why people do or 
don't get better. I hope that it will take 
less than a blinding light or a clap of 
thimder to get this fairly obvious point 
across to the herbalists. 

If the alternative medicine converts 
wish to help us understand how better 
to relate to our patients, that is to be 
commended. But they do not advance 
knowledge by grandiose generalities 
and unsubstantiated claims of miracu- 
lous healing, characterized by much of 
Dr. Weil's book, which is cited uncrit- 
ically in the Bulletin interview. As Dr. 
Arnold S. Relman pointed out, there 
really is no such thing as "alternative" 
medicine — only medicine that has 
proved to work and medicine that has 
not (Relman, Arnold S., Alternative 
Medicine: A Shot in the Dark, Wall 
Street Journal, ]uly 12, 1995). 

I could work up a worry that the 
uncritical nonsense in the Weil inter- 
view reflects that Harvard Medical 
School has soared off into space, seized 
by some exotic antiscience fervor that 

tries to talk up a case for basic medi- 
cine but puts it aside for the imagined 
healing power of herbs, tonics, medita- 
tion, hypnosis and massage, to list a 
few of Dr. Relman's understandable 
vexations. It is of interest that almost 
coincidental with the Bulletin 'j 
"Considering the Alternatives" was the 
arrival of the September issue oi Life 
magazine, which carried a story of the 
Harvard-trained physician, shown cov- 
ered with, I guess, mud, holding a 
sprig of peppermint. I am sorry that if 
that picture had been available to the 
Bulletin, it was decided not to use it. It 
would have made an appropriate 
unreal illustration for your unreal 
account that passes for an interview. 

Allow me the charitable assumption 
that the Weil puffery was a quirk of 
the Bulletin and not reflective of the 
school or of the issue as a whole and its 
better entries, notably that of my dis- 
tinguished former N.Y. U. colleague, 
Gerald Weissmann on "Mesmerism 
and Kindred Delusions." Leaving aside 
his arguable general concept of 
"progress," Dr. Weissmann's antidote 
to your advertised nostrums helped to 
save this issue from being a clairvoyant 

It is my opinion, nonetheless, that 
the interview with Dr. Weil is an 
example of incompetent journalism, 
and the article reflects sloppy editing. 

Lester Grant 'jj 

Editor-in-Chief William Ira Bennett '68 

The content of the Bulletin is deter- 
mined by the editors. No single article 
or issue is meant to represent the 
school's official position, or anyone 
else's for that matter. Our hope is that, 
over time, the Bulletin will cover a 
range of topics and viewpoints reflect- 
ing the diversity of the school's 
alumni, faculty and students. 

Sense and Sensibility 

Thank you for devoting the Summer 
issue of the Bulletin to alternative med- 
icine. Ever since my career was 
enhanced by returning to theology 
school in 1976, 1 have been seeking 
ways in which to teach and practice 
holistic medicine. By that, I mean the 
integration of body, mind and spirit in 
health care. 

My emphasis has been on patients 
assuming responsibility for their own 
health and health care, using my med- 
ical expertise as educator and coun- 
selor. Listening to the patients' views 
of their health care needs and goals has 
led me over and over to take a rational 
look at alternatives to American allo- 
pathic medical tools. Certainly, we 
must use clinical discernment in decid- 
ing which alternative therapies are 
rationally based and can be subjected 
to scientific investigation. 

Benson's article on transcendent 
faith and belief in God accords with 
my experience in medical practice. 
Many times I have prayed with my 
patients as they have confronted major 
life issues and losses, recognizing that I 
am affirming their faith system. 
Nelson's article on native healing 
again underscores the significance of 
using the patients' faith in the health 
care process. 

The jarring article in this issue is 
Weissmann's article on mesmerism, in 
which he takes potshots at several 
alternative medical tools. The nub of 
my concern is his contrasting "reduc- 
tionist, scientific medicine" (which he 
espouses) and a variety of alternatives 
(which he decries). It appears that 
Weismann would dualistically keep 
separate techniques that are physical 
and those that are mental and/or spiri- 

I believe that our medical entry 
into the next millennium should be 
marked by the integration of therapeu- 

WlNTER 1997 



tic tools that address body, mind and 
spirit. This has been eloquently 
demonstrated by Jon Kabat-Zinn in 
his work at the University of 
Massachusetts Medical Center Stress 
Reduction Clinic. Colleag-ues from 
that medical center refer patients to 
him for a unique therapy, which serves 
as an adjunct to "traditional" treat- 
ments and allows the patients to gain 
some mastery over the psychological 
and spiritual "dis-ease" engendered by 
their chronic disease conditions. 

Let us support the research being 
promoted by the Office of Alternative 
Medicine at the National Institutes of 
Health. By subjecting hypnosis and 
homeopathic therapies, as well as 
other alternatives, to the rigors of clin- 
ical testing, we may come closer to 
knowing which therapies have clinical 

Thomas C. Washburn 'yy 

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HMS '66 

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Next Dean Chosen 

Joseph B. Martin, chancellor of the 
University of California at San 
Francisco, will be the next dean of the 
Faculty of Medicine at Harvard. 
Martin will assume the deanship on 
July I, 1997, when Daniel C. Tosteson 
steps doviTi after 20 years as dean. 

A leading neurologist and educator, 
Martin has served as chancellor of 
UCSF since 1993 and was dean of the 
UCSF School of Medicine from 1989 to 
1993. Previously, he was professor of 
medicine at HMS and chief of the neu- 
rology service at mgh for more than a 

"Joseph Martin is a person of extra- 
ordinary wisdom, effectiveness, and 
experience," President Neil L. 
Rudenstine said. "He is a distinguished 
neurologist who has devoted his career 
to pursuing and affirming the highest 
standards of excellence in medical edu- 
cation and research. He has been a 
thoughtful, coUegial, and successful 
leader of a large and complex academic 
medical center, and he has a thorough 
understanding of the fundamental 
changes in health care delivery systems 
that are transforming the environment 
for academic medicine, both locally 
and nationwide. Harvard will be 
extremely fortunate to have Joseph 
Martin guiding our faculty of medicine 
into the next century." 

"I am deeply honored by this 
opportunity to rejoin the academic 
community at Harvard," Martin said. 
"The challenges we face in academic 
medicine require the investment of 
dedicated energy if we are to maintain, 
let alone strengthen, the remarkable 
achievements in health care and bio- 
medical research of the past decades. I 
am eager, with the help of the out- 
standing faculty and others throughout 
the Harvard medical community, to 
guide the faculty of medicine through 
these unusually challenging times." 

During his tenure as dean of UCSF 
School of Medicine, Martin is credited 
with having recruited numerous dis- 
tinguished physicians and scientists to 
the UCSF faculty, and having guided 
the school through a period of con- 
strained resources. He became known 
for his efforts to stimulate cooperative 
efforts between basic scientists and 
clinical investigators, in order to bring 
the results of medical research more 
directly to bear on patient care. As 
dean, Martin was instrumental in 
establishing the Keck Center for 
Integrative Neurosciences, dedicated 
to combining studies of the brain and 
human behavior. He also oversaw the 
final development of San Francisco's 
General Hospital's Gladstone Institute 
for Virology and Immunology, which 
is dedicated to aids research. 

In 1993 Martin was named chancel- 
lor of UCSF, a university devoted to 
health sciences and comprising schools 
of medicine, dentistry, nursing, and 
pharmacy, as well as related programs 
of graduate education and research. As 
chancellor, Martin has been one of the 
principal architects of a proposed 
merger between the hospitals of UCSF 
and Stanford University, which awaits 
approval by the Board of Regents of 
the University of California. Other 
highlights of Martin's tenure as UCSF 
chancellor include progress toward the 
completion of a National Cancer 
Institute-designated comprehensive 
care center at UCSF, the successful 
completion of UCSF's first-ever capital 
campaign, which raised more than 
$550 milhon; the preparation of a 
long-range development plan, in close 
consultation with community leaders, 
for the renewal of UCSF's main campus 
and the development of a second one; 
and the formation of an office of tech- 
nology management to help foster 
appropriate links between university 
researchers and private industry. 

Harvard Medical Alumni Bulletin 

Joseph B. Martin 

Martin began his Harvard career in 
1978, the year after Daniel Tosteson 
became dean of Harvard's faculty of 
medicine. The Julieanne Dorn 
Professor of Neurology at HMS from 
1978 to 1989, Martin also headed the 
neurology service of the MGH. His own 
research focused on hypothalamic 
pituitary regulation, the role of neu- 
ropeptides in brain function, and the 
use of molecular genetics to advance 
understanding of the causes of neuro- 
logical and neurodegenerative disease. 
In 1980 Martin helped found the NIH- 
supported Huntington's Disease 
Center in Boston, bringing together 
collaborators from several universities. 
Investigators in the center located a 
genetic marker near the gene for 
Himtington's chorea. That finding, a 
milestone in molecular biology, made 
it possible to test for this neurological 
disorder before symptoms appear. 

Tosteson warmly praised the 
appointment of his successor. "Joseph 
Martin is superbly qualified to serve as 
dean of the Faculty of Medicine at 
Harvard University," Tosteson said. 
"He is an accomplished and distin- 
guished scholar in clinical neurology 
and basic neuroscience. He has had 
excellent experience in the administra- 
tion of complex modem academic 
medical centers in Boston and in San 

Francisco. Best of all, he is a percep- 
tive, courteous, wonderful human 
being. I am proud that he will succeed 
me as dean and happy to welcome him 
and his wife, Rachel, back to Harvard 
and to Boston. I congratulate him and 
thank President Rudenstine and his 
faculty advisory group for a wise and 
successful outcome to a careful 

"I said at the outset of this search 
that finding a worthy successor to Dan 
Tosteson would be an extremely diffi- 
cult task," Rudenstine said. "Dan has 
been — and for the rest of this acade- 
mic year will continue to be — an 
absolutely outstanding leader of our 
faculty of medicine, and all of us owe 
him an enormous debt of gratitude. 

"I also want to thank literally hun- 
dreds of people who offered me 
thoughtful advice during the course of 
the search," Rudenstine added. He and 
Albert Carnesale, the university's 
provost, met every two weeks with a 
1 5 -member faculty advisory group 
throughout the summer and fall. They 
received more than 150 letters con- 
cerning the search, reviewed the 
names of more than 100 nominees, 
and consulted several dozen advisors — 
at Harvard and the medical commu- 
nity at large — for advice. 

A native of Alberta, Canada, Martin 

received his medical degree in 1962 
from the University of Alberta. He was 
a resident in neurology and a fellow in 
neuropathology at Case Western 
Reserve University, and went on to 
receive his PhD in anatomy from the 
University of Rochester in 1971. From 
1970 to 1978, he served on the faculty 
of McGill University in Montreal, 
where he rose to become professor of 
medicine and of neurology, and chair- 
man of the Department of Neurology 
and Neurosurgery. 

In 1 989 Martin was chosen by the 
Institute of Medicine of the National 
Academy of Sciences to chair a com- 
mittee on "mapping the human brain." 
The committee's 1991 report emerged 
as a major guide for policymakers and 
federal agencies responsible for sup- 
porting and directing the Human 
Brain Project. 

The author or coauthor of more 
than 200 scientific articles, Martin is 
one of the editors of Han-isoit \ 
Principles of Medicine, a widely used 
medical textbook. He has served on 
the editorial boards of the New 
England Journal of Medicine and Science 
and as an advisor for the development 
of national policy on biomedical 
research. He is a member of the 
Institute of Medicine, a fellow of the 
American Academy of Sciences, a 
member of the American Association 
of Physicians, a fellow of the American 
Association for the Advancement of 
Science, and a member of the 
American Neurological Association, of 
which he served as president in 1989. 

Martin currentiy lives in San 
Francisco with his wife, Rachel. They 
have four children. 

Winter 1997 


The First Class of the 2000s 

The first class of the new millenium 
has matriculated and, as in past years, 
Harvard received a record number of 
applications. "Close to 4,000 students 
applied to HMS this year," says Gerald 
Foster '51, associate dean for admis- 
sions and chairman of the Committee 
on Admissions. "The candidates were 

Despite this record-setting number, 
there are indications that the applicant 
pool will change in the coming year. 
"For a while, applications to medical 
school went sky-high due to concerns 
about other job markets, but now the 
tables are turning," says Foster. 
"Medicine is still an exciting career, 
but with the revolution in health care 
and the marketplace undergoing great 
changes, along with the economic cli- 
mate improving in other fields, a drop 
is expected in the next year." 

What has not changed is that 
women hold a slight majority in the 
incoming class for the third year in a 
row: of the 166 students, there are 89 
women and 76 men. Twenty percent 
of the first-year class is under-repre- 
sented minorities, and the trend of the 
older or "nontraditional" student con- 
tinues, with 38 of the entering class 
between the ages of 25 and 38. In fact, 
HMS actively pursues these older stu- 
dents."! like to say that the nontradi- 
tional students bring a lot of leavening 
to a class," says Foster. 

There is also a geographically 
broad spectrum to the class. Students 
come from as far as Barbardos, 
Bulgaria, Canada, the Czech Republic, 
Ghana, Peru and Puerto Rico. Over 25 
states are represented, with California 
topping the list of the "double digit 
states" with 36 students, followed by 
Massachusetts (a record number 26), 
19 from New York (the lowest ever) 
and 1 1 from Maryland. 

Shan Liu receives her 
wliite coat, as part of an 
orientation ceremony, 
from IVIarian Neutra, mas- 
ter of the Castle Society. 

As in the past, the largest number 
of college graduates comes from 
Harvard/Radcliffe (42); Stanford is 
second with 14, and Princeton is third 
with 13. The remainder of the stu- 
dents come from 53 other colleges. 

"This class has stunning records of 
academic achievement along with 
equally impressive personal qualities, 
classroom activities and life experi- 
ence," says Foster. The evidence is 
certainly found in the statistics: the 
total average MCAT score is over 2 and 
a half points higher than the national 
average, and more than 60 percent of 
the students had science GPAs between 
3.75 and 4.00. 

As part of orientation activities, 
groups of second-year students accom- 
panied over half the entering class on a 
four-day backpacking/camping trip. 
For the third year, FEAT (First- Year 
Education Adventure Trip) provided 
an opportunity for entering students to 
enjoy the woods of New Hampshire 
and Maine while talking with second- 
year students about beginning their 
medical careers. 

During orientation week Edward 
M. Himdert '84, associate dean for 
student affairs, told the entering class 
"to stop worrying that they were the 
one admissions committee mistake 
because everyone else has discovered a 
cure for a rare tropical disease or 
earned two Phos in molecular genetics 
before entering HMS." 

"To parody the routine used at cer- 
tain fiercely competitive business and 
law schools: look at the person to your 
left and your right and be warned that, 
as a statistical weeding out process, the 
administration of this school expects 
all three of you to graduate and 
become doctors. It is with this goal in 
mind that we have designed a curricu- 
lum and an educational experience 
where collaboration, rather than com- 
petition, guides the learning." 

Harvard Medical Alumni Bulletin 


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Bad Mouse Moms 

By knocking out a single gene, 
Harvard Medical researchers at 
Children's Hospital have created a 
strain of mutant mice that ignore their t 
infants. It is considered a powerful S 
demonstration of the effect that one J 
gene can have on animal behavior. o 


Normal mice, which carry the fosB "§■ 
gene, immediately care for their new- 
born pups: clean and suckle them, 
crouch over them to keep them warm, 
and keep them gathered together. 
Mice that lack that gene exhibit none 
of these nurturing behaviors. 

"They go and explore the pups and 
sniff them, but then go to the corner 
of the cage and ignore them," says 
Michael Greenberg, HMS professor of 
neurology and director of the Division 
of Neuroscience at Children's. His 
laboratory's findings appeared in the 
July 26 issue of Cell. 

The missing gene belongs to a 
poorly understood class of genes 
known as immediate early genes 
(lEGs). lEGs are known to be rapidly 
induced by stimuli outside the cell, 
such as growth factors and, in the case 
of neurons, neurotransmitters. Once 
turned on, they produce transcription 
factors which, in turn, induce the 
expression of other genes. FosB might 
be exerting its widespead effects by 
turning on a variety of other genes 
within a critical brain region responsi- 
ble for modulating the behaviors 
involved in nurturing, speculates 

When she set out to find out more 
about the fosB gene in 1992, Jennifer 
Brown, an MD/phD student in 
Greenberg's lab, had no idea that the 
gene would have anything at all to do 
with nurturing behavior. Two years 
later, she had her first generation of 
mutants, but initially was extremely 
disappointed: they all looked normal. 
It was when she mated the mutants 

with one another that she got the stun- 
ning results. Most of the offspring 
died; it was only when they were 
adopted by normal mice moms that 
they could survive. Their mammary 
glands were normal, the researchers 
subsequently established, but their 
nurturing instinct was not. 

The researchers are now exploring 
how fosB acts in the preoptic area of 
the hypothalamus, an area of the brain 
knovrai to play a role in nurturing 
behavior. They want to see how fosB 
interacts with other genes and hor- 
mones and try to get at the molecular 
basis for nurturing behavior. "It's 
obviously going to be a lot more com- 
plex than just fosB," says Greenberg. 

As fosB is also present in higher 
mammals and humans, their work in 
mice may provide clues to understand- 
ing human nurturing behavior as well, 
though the researchers caution that no 
concrete extrapolation can be made at 
this time. 

Winter 1997 


Publishing Initiative Launched 

Harvard Medical School and the pub- 
lishing company Simon & Schuster are 
teaming up to publish books, newslet- 
ters and electronic products on con- 
sumer health and health care 
leadership. The various projects will 
be designed to empower patients and 
doctors through the dissemination of 
authoritative consumer and health care 
management information under the 
HMS imprimatur. 

Among the first major works to be 
produced will be "The Harvard 
Medical School Family Health 
Guide," a book and CD-ROM to be 
released in 1998. Other health guides 
being considered include ones geared 
to senior citizens, to parents, one on 
nutritional medicine and another on 
medications. The partnership also 
expects to translate and distribute new 
and existing HMS newsletters — such as 
the Harvard Health Letter — overseas. 

Simon & Schuster Audio plans to 
publish audiobooks related to health 
promotion and stress reduction. And 
Jossey-Bass, Simon & Schuster's San 
Francisco-based publisher for profes- 
sionals, leaders and executives will 
publish books, periodicals and training 
materials in two series, one focusing 
on the business of health care and the 
other on medical computing. 

The Harvard side of the initiative is 
to be led by Anthony L. Komaroff, 
HMS professor of medicine and direc- 
tor of the Division of General 
Medicine and Primary Care at 
Brigham and Women's Hospital. "The 
Harvard Medical School faculty repre- 
sents a tremendous resource of health 
care expertise," said Komaroff. "In 
partnering with Simon & Schuster we 
are creating a truly powerful combina- 
tion for bringing important and reli- 
able medical information to a wide 

Scholars in Medicine Honored 

Graduate students often come into the 
office of Chao-ting Wu, assistant pro- 
fessor of genetics at HMS, close the 
door, and ask her, "Is it worth it?" 
This question undoubtedly refers to 
the challenges both women and 
minorities face in reaching the junior 
faculty level at HMS and then continu- 
ing up the academic ladder. 

Wu and nine other junior faculty 
will get some help facing these chal- 
lenges through the 50th Anniversary 
Program for Scholars in Medicine fel- 
lowship awards. Ten awards, each in 
the amount of $25,000, are targeted to 
junior faculty who typically do not 
have independent funding and are in 
the midst of writing grants, establish- 
ing a clinical practice, tr3nng to publish 
and do research, while juggling profes- 
sional and personal responsibilities. 
The fellowship recipients were hon- 
ored at a reception at the medical 
school on October 9. 

Anthony Komaroff, Dean 
Tosteson and Jonathan 
Newcomb, CEO of Simon 
& Schuster. 

Harvard Medical Alumni Bulletin 

The fellowship awards were 
announced last spring and over 200 
junior faculty from HMS and its affih- 
ated institutions applied. A committee 
chose seven junior faculty to receive 
the fellowships, with another three 
faculty also awarded fellowships in a 
separate process at Charming 
Laboratories and Harvard Pilgrim 
Health Care. 

It was a proud and happy group of 
sponsors, donors and alumnae that 
assembled for the reception. After wel- 
coming remarks by Dean Tosteson, 
Eleanor Shore '55 — dean for faculty 
affairs and chair of the 50th anniver- 
sary committee — introduced the recip- 
ients, who described their research 
interests and how they plan to use 
their awards. 

Elaine Hylek, instructor of medi- 
cine at Massachusetts General 
Hospital, and recipient of the Alumnae 
and Friends Fellowship, expressed her 
thanks to Harvard for both seeing the 
need for the program and acknowledg- 
ing the difficulty in getting an acade- 
mic career started. "I am so excited 
and thrilled. It's a symbol that HMS as 
an institution cares about the lower 
rung. We're not Nobel prize winners 
but struggling to get there." 

For Hylek, whose research focuses 
on stroke and stroke prevention, the 
fellowship will free up time for her "to 
pursue research and write the papers 
that have been on my desk for nine 
months." In addition, the money will 
be used as a bridge to independent 

Eleanor Shore 

funding. Other recipients will also use 
their money to access independent 
funding, as well as hire laboratory sup- 
port staff, conduct studies or write 

Shore, who initiated the fellowship 
program as part of the 1995 celebra- 
tion that honored the 50th anniversary 
of women being admitted to HMS, sees 
the long-term impact of these awards. 
"These recipients give us fresh hope 
that the present statistics (only seven 
percent of full professors at HMS are 
women and only two percent are 
minorities) will be looked at as fossils 
in the future." 

Shore, who with her husband Miles 
Shore are the donors of the Eleanor 
and Miles Shore Fellowship, notes that 
"The true winners will be the fields of 
medicine in which these recipients 
work." Indeed, the awardees are cover- 
ing much medical terrain including 

Chao-ting Wu and her 

HIV, cholesterol, violence prevention 
and CMV. 

There will be 50 fellowships 
awarded through the year 2,001, 40 of 
which are already funded. The follow- 
ing is a list of the recipients and their 

Evan Abel, MBBS, DPhil, instructor in 
medicine, Beth Israel Hospital, 
Eleanor and Miles Shore Fellowship 

Sandra Burchett, MD, assistant professor 
of pediatrics. Children's Hospital, 
Children's Hospital Department of 
Medicine Fellowship in honor of Dr. 
Mary Ellen Avery 

Leticia Castillo, MD, assistant professor 
of pediatrics, Massachusetts General 
Hospital, Lynne M. Reid Fellowship 
in memory of Violet and Robert Muir 

Winter 1997 


Lisa Diller, MD, assistant professor of 
pediatrics, Dana Father Cancer 
Institute, Children's Hospital 
Department of Pathology Fellowship 
in honor of Dr. Lynne M. Reid 

Anita Feins, MD, clinical instructor in 
pediatrics. Harvard Pilgrim Health 
Care, Harvard Pilgrim Health Care 
Foundation Fellowship in memory of 
Dr. Robert H. Ebert 

Diane Ruth Gold, MD, MPH, assistant pro- 
fessor of medicine, Channing 
Laboratory, Brigham and Women's 
Hospital, Edward and Amalie Kass 

Hilde-Kari Guttormsen, MD, PhD, instruc- 
tor in medicine, Channing Laboratory, 
Brigham and Women's Hospital, 
Edward and Amalie Kass Fellowship 

Elaine Hyiek, MD, MPH, instructor in 
medicine, Massachusetts General 
Hospital, Alumnae and Friends 

Francine Weity, MD, PhD, instructor in 
medicine, New England Deaconess 
Hospital, Irving and Charlotte Rabb 
Fellowship in memory of Dr. Grete 

Chao-ting Wu, PhD, assistant professor of 
genetics. Harvard Medical School, 
Richard and Priscilla Hunt Fellowship 

No Humbug 

Anesthesia is something the world has 
come to take for granted. Not so on 
October i6, 1846, when a Boston den- 
tist by the name of William T.G. 
Morton administered ether to a 
patient, who, following removal of a 
jaw tumor, informed the skeptical 
audience that he had felt no pain. 
While the patient was being carried 
from the operating theater, MGH's 
chief surgeon, John Collins Warren, 
who had performed the operation, 
turned and faced the incredulous 
assemblage of onlookers, commenting, 
"Gentlemen, this is no humbug." 
News of the discovery spread quickly, 
and within months it was hailed as the 
"greatest gift ever made to suffering 

This fall HMS and MGH celebrated 
the 150th anniversary of Morton's first 
demonstration of ether anesthesia, 
thus reminding us of the dramatic 
effect this event had on surgical medi- 

Kathleen and Richard 
Warren, descendants of 
the Warren family, in 
front of the Robert 
Hincitley painting. First 
Operation Under Ether. 

cine — transforming it from a primitive 
torture to a far gentler art. Countway 
Library mounted an exhibition of 
paintings depicting the historical 
demonstration. During the one-month 
exhibition, Robert C. Hinckley's well- 
known pictorial recreation of "The 
First Operation Under Ether" was 
flanked by original portraits in oil and 
crayon of the four persons associated 
with the discovery and introduction of 
surgical anesthesia: Horace Wells, 
Charles T. Jackson, William T.G. 
Morton and Crawford Long. 

The opening of the Countway 
exhibition coincided with MGH's cel- 
ebration on October 16-17. A number 
of medical luminaries participated in 
the two-day conference, including 
HMS's Francis D. Moore '39, 
Guillermo Sanchez '49, Samuel O. 
Thier, David H. Sachs '68, M. Judah 
Folkman '57, Patricia L. Donahoe and 
Philip Leder, '60, among others. 

The celebration opened with a 


Harvard Medical Alumni Bulletin 

Kristen Kroll 

Boston tour that highlighted MGH's 
Ether Dome, the Monument to Ether 
at Boston Pubhc Garden, and the 
graves of Morton, Holmes, Jackson 
and Bigelow at Mt. Auburn Cemetery. 
The 150th anniversary included a 
number of historical presentations on 
everything from the nature of surgery 
in 1 846 to the personalities involved 
with the first anesthesia trials. 

Appropriately enough, the second 
and final day of the Ether Day celebra- 
tion took a look at twentieth century 
medicine and beyond in such presenta- 
tions as Thier's "Health Care Policy 
and Hope for the Future" and Leder's 
"Cancer: Is it Really a Genetic 

Just Add Some DNA and a Pinch of Extract 

Thanks to Kristen Kroll, the trans- 
genic mouse now has some competi- 
tion in the field of genetically altered 
animals. Kroll, a postdoctoral fellow in 
the HMS Department of Cell Biology, 
has created an easy and inexpensive 
method to produce a genetically 
altered frog, which will allow easy 
study of the molecular pathways in 
frog embryology. This method, which 
she is now teaching to scientists 
throughout the world, was described 
in the October issue of Development. 

African clawed frogs have been 
widely used by embryologists for years 
due to their large egg size and ease 
with which the eggs grow in a culture 
dish. Earlier research attempts at 
injecting nucleic acids into frog eggs 
were not successful, however. "We 
really needed the means to achieve sta- 
ble integration of introduced DNA in 
the embryos and to fine-tune the time 
and place of expression," says Kroll, 
who works in the laboratory of Marc 
Kirschner, the Carl Walter Professor 
of Cell Biology. Kroll began this work 
as a graduate student at University of 
California at Berkeley, where she 
developed a method that was not as 
efficient or refiable. 

Before she left UCal/Berkeley, she 
teamed up with Enrique Amaya, who 
as a graduate student had worked in 
Kirschner's lab. Together, they cre- 
ated a "recipe" that can treat as many 
as 500 eggs in an hour, with 10 to 20 
percent of these eggs becoming 

embryos. The recipe consists of com- 
bining sperm nuclei and the DNA con- 
struct into a tube, adding an enzyme 
that permits the DNA construct to 
insert itself into the sperm DNA, then 
adding an extract to facilitate the 
insertion. After this mix incubates for 
ten additional minutes, it is transferred 
to a capillary tube and injected into 
freshly harvested frog eggs. 

Quite a simple procedure, as Kroll 
notes: "All you need to do is show up 
in the lab, fix up your mix, and shoot it 
in. The next day you can analyze your 
embryos, and study how the intro- 
duced gene affects their development." 

KroU's and Amaya's method is cost- 
effective as well. All the requisite 
materials are found in any embryology 
lab, at a cost of about $1,000, as com- 
pared to the $100,000 necessary to 
equip labs that produce transgenic 
mice. This method "offers invaluable 
advantages," says Kroll, and creates 
considerable research potential, partic- 
ularly at the earhest embryonic stages. 

Winter 1997 


Grumpy Old Men 

A new study demonstrates just how 
risky it may be for a grumpy and impa- 
tient man to be stuck in traffic. Ichiro 
Kawachi, assistant professor of medi- 
cine at HMS, and coworkers foimd that 
extreme forms of anger can increase 
the risk of heart attack in older men by 
as much as three times. The resuks of 
this study were pubhshed in the 
November i issue of Circulation. 

The researchers followed 1,305 
Veterans Administration patients for 
seven years, beginning in 1986. 
During this period, there were no 
cases of coronary heart disease, includ- 
ing 20 fatal and 30 nonfatal heart 
attacks. Anger was measured by a writ- 
ten questionnaire. "We're talking 
about extreme anger here," says 
Kawachi. "From the kinds of questions 
we asked the subjects, some felt like 
exploding, others were constantly irri- 
table and grouchy, still others would 
hurt furniture and even other people. 
This is not the common garden-vari- 
ety irritation that we might feel." 

Kawachi and colleagues asked these 
otherwise healthy men (between the 
ages of 40 and 90) questions like "At 
times, do you feel like swearing, 
smashing things, kicking that slow per- 
son in line?" They then ranked their 
answers on a scale from o to 14. The 
higher the score, the greater the risk of 
a heart attack or angina. "Anger 
releases stress hormones like adrena- 
lin, which increases the stickiness of 
the blood and can cause clotting in the 
coronary arteries and heart attack," 
explains Kawachi. 

Kawachi's results are reminiscent of 
another Harvard study done in 1995 
that showed the risk of heart attack 
more than doubled two hours after 
moderate to intense anger. "Our study 
demonstrates a longer term increase in 
the risk among older men," notes 

Although many doctors now rec- 
ommend taking aspirin daily to reduce 
the chance of blood clots forming, 
Kawachi says he wants to see more 
studies before he would recommend 
this practice, but does note that aspirin 
has a moderate protective effect. He 
does recommend quitting smoking, 
exercising to reduce stress, and anger 
management counseling. 

Of Primary Concern 

Jordan Cohen '60, president of the 
AAMC, was the speaker at HMS's 
National Primary Care Day celebra- 
tion in October. "A consensus is now 
emerging in the medical education 
community that embedding the con- 
cepts and principles of generalism in 
the medical school curriculum has 
value for the education of every med- 
ical student," he commented. "The 
challenge for U.S. medical schools in 
the 2 1 St century will be to provide all 
medical students with a firm generalist 
foundation, no matter what kind of 
medicine they eventually choose to 

HMS celebrated National Primary 
Care Week with a number of presen- 
tations at the Medical Education 
Center. Nakela Cook, a second-year 
student, gave a talk entitled "The 
Family Van — ^Mobile Primary Care 
Services for Boston." She described 
her experiences working with the 
mobile clinic. Karen Carlsen, of the 
MGH, gave a talk about delivery of pri- 
mary care and preventive medicine to 
women. There was a presentation on 
"Alternative Medicine and Primary 
Care," and Tim Perrin, of the MGH, 
gave a talk on the prospects for univer- 
sal coverage entitled "Health Care for 
Uninsured Children." The week con- 
cluded with a discussion by 4th-years 
describing why they chose primary 

Interest in the primary care career 

option is growing at HMS. More than 
half of the graduating class of 1996 
entered generalist residencies, such as 
internal medicine, pediatrics, obstet- 
rics and gynecology and family prac- 
tice. Under the direction of Thomas 
Inui, the Primary Care Division at 
HMS has implemented many programs 
to nurture students interested in pur- 
suing careers as primary care physi- 
cians. Among them is the year-long 
primary care clerkship. This clerkship, 
which will be inaugurated in January 
1997, will give students the opportu- 
nity to care for patients over a long 
period of time. 

We're Honored 

The Harvard Medical Mumni 
Bulletin recently won an Award 
of Excellence, the highest 
honor in its category, external 
publications, from the 
Association of American 
Medical Colleges. The winning 
issues were from 1995: the 
mind, brain, behavior issue 
(with hologram on cover), the 
women's issue, and the one 
entitled "Living Memory." 

Harvard Medical Alumni Bulletin 

President's Report 

by Suzanne W. Fletcher 

The packed agenda of die Alumni 
Council's November 15, 1996 meeting 
included happy discussion of President 
Rudenstine's announcement that Dr. 
Joseph Martin, chancellor of the 
University of California at San 
Francisco, will be the next dean of HMS 
(see page 4). He succeeds Daniel 
Tosteson '49 who is stepping down 
June 30, 1997 after 20 years as dean. 

The Alumni Office is going elec- 
tronic, with its own Home Page 
Alumni with access to the Internet can 
now get information about alumni 
reunion dates and other activities right 
on the computer. Perhaps as an out- 
growth of the networking capabilities 
that come with this electronic age, the 
council began a discussion of new ser- 
vices that might help alumni. Several 
council members polled alumni in 
their pentads for ideas. Suggestions 
tended to follow the phases of Hfe, 
with new alumni expressing need for 
debt service aid, middle-aged alumni 
asking for help with business and man- 
agement skills, and "mature" alumni 
requesting programs for those nearing 
retirement. The council will continue 
these discussions at our winter meet- 
ing in February. Meanwhile, I encour- 
age all those with ideas to contact us. 

Dean Tosteson shared with the 
council the curriculum changes intro- 
duced into the third and fourth years. 
As the care of patients moves from 
hospital wards to ambulatory sites, 
there are new needs for patients and 
teachers. Medicine and surgery clerk- 
ships have been expanded from two- to 
three-month blocks. Students spend 
the extra month in ambulatory settings 
to learn care of patients with illnesses 
that no longer require admission to 
the hospital. 

A new year-long Longitudinal 
Primary Care clerkship will begin in 
January 1997 for all third-year medical 

students. The students will work one- 
half day per week in the office of a 
general internist, general pediatrician 
or family physician in the Boston area. 
It is hoped that over the course of the 
year students will not only learn what 
primary care involves but will build a 
small panel of patients whom they fol- 
low over time, so they can have an 
opportunity to experience the privilege 
of long-term relationships between 
doctors and patients. Alumni in the 
Boston area who might like to precept 
a student in their office or who want to 
learn more about the program should 
contact Robert Fletcher ^66, clerkship 
director (phone: 61 7-421 -601 3; fax: 
617-85981 12; e-mail: rfletch@war- 

The council heard that it is increas- 
ingly difficult to find patients with cer- 
tain physical findings for second-year 
medical students learning physical 
diagnosis in the Patient/Doctor II 
course. For example, when students 
are learning the cardiac examination, 
patients with various murmurs are no 
longer easily available for examination 
on the hospital wards. Faculty increas- 
ingly call on ambulatory patients will- 
ing to help by spending an occasional 
afternoon with several students. The 
council discussed a suggestion that the 
Alumni Office coordinate efforts of 
nearby alumni with suitable patients 
who would like to help. Richard 
Hannah ^66, former council treasurer, 
told of responses to the idea from his 
patients and pointed out that a number 
of administrative and logistic chal- 
lenges need attention for such an idea 
to work. Meanwhile, any alumni inter- 
ested in learning more about the pro- 
posal or who have suggestions should 
contact Nora Nercessian (617-432- 
1560; email: 

William Silen, faculty dean for fac- 
ulty development and diversity. 

described the Mentoring Award, annually 
given to a faculty member who has been 
an outstanding mentor to students, resi- 
dents or junior colleagues. (Marshall 
Wolf '63 received the 1996 award.) The 
council agreed that in addition to the 
present award, a new Alumni Association 
Mentoring Award should be created, 
with alumni making the nominations. Bill 
Silen will call for nominations soon, and 
can be contacted at 6 17-43 2-106 1. 

As I hope is clear from this report, the 
Alumni Council has not only gone elec- 
tronic, but wants to be interactive as well. 
We want to hear from more of the 8,500 
alumni, so please feel free to react to 
some of the ideas reported, and suggest 
new ones as well. Let us hear from you. 

Alumni Association Officers 

Suzanne Fletcher ^66 (617-42 1 -601 1) 
Roman W. DeSanctis '55 (617-726-2889) 
Robert S. Lawrence '64 (410-614-4590) 
George E. Thibault '69 (617-732-8515) 
Arthur R. Kravitz '54 (617-244-3697) 
David D. Oakes '68 (408-885-6060) 


Alison G. May '91 (617-522-4700) 
Dana Leifer '85 (203-737-4087) 
Katherine L. Griem '82 (312-942-5751) 
Laurie R. Green '76 (415-379-9600) 
Sharon B. Murphy '69 (312-880-4584) 
Gilbert S. Omenn '65 (206-543-1144) 
Gerald T. Keursch '62 (617-636-7004) 
John B. Stanbury '39 (617-277-3545) 
David P. Gilmour '66 (603-883-2226) 
Chester d'Autremont '44 (617-259-8155) 


Daniel C. Tosteson '48 (61 7-43 2-1 501) 
Daniel D. Federman '53 (617-432-1497) 
Wilham I. Bennett '68 (617-576-6199) 

Nora N. Nercessian (617-432-1560) 

Suzanne IV. Fletcher '66 is HMS professor of 
ambulatory care and prevention at Harvard 
Pilgrim Health Care. 

Winter 1997 



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The Dying Inayat Khan 

India (Mughal) 

Francis Bartlett Donation of 191 2 

and Picture Fund, courtesy, 

Museum of Fine Arts, Boston 


Harvard Medical Alumni Bulletin 

Ode to a Nightingale 

John Keats, 1819 

My heart aches, and a drowsy numbness pains 

My sense, as though of hemlock I had drunk, 
Or emptied some dull opiate to the drains 

One minute past, and Lethe-wards had sunk: 
'Tis not through envy of thy happy lot. 

But being too happy in thine happiness, — 
That thou, light-winged Dryad of the trees. 
In some melodious plot 
Of beechen green, and shadows numberless, 
Singest of summer in full-throated ease. 

O, for a draught of vintage! that hath been 

Cool'd a long age in the deep-delved earth. 
Tasting of Flora and the country green. 

Dance, and Provengal song, and sunburnt mirth! 
O for a beaker full of the warm South, 

Full of the true, the blushful Hippocrene, 
With beaded bubbles winking at the brim, 
And purple-stained mouth; 
That I might drink, and leave the world unseen. 
And with thee fade away into the forest dim: 

Fade far away, dissolve, and quite forget 

What thou among the leaves hast never known. 
The weariness, the fever, and the fret 

Here, where men sit and hear each other groan; 
Where palsy shakes a few, sad, last gray hairs. 

Where youth grows pale, and spectre-thin, and dies; 
Where but to think is to be full of sorrow 
And leaden-eyed despairs. 
Where Beauty cannot keep her lustrous eyes. 
Or new Love pine at them beyond to-morrow. 

Away! away! for I will fly to thee, 

Not charioted by Bacchus and his pards. 
But on the viewless wings of Poesy, 

Though the dull brain perplexes and retards: 
Already with thee! tender is the night. 

And haply the Queen-Moon is on her throne, 
Cluster'd around by all her starry Fays; 
But here there is no light, 
Save what from heaven is with the breezes blown 

Through verdurous glooms and winding mossy ways. 

I cannot see what flowers are at my feet, 

Nor what soft incense hangs upon the boughs. 
But, in embalmed darkness, guess each sweet 
Wherewith the seasonable month endows 
The grass, the thicket, and the fruit-tree wild; 
White hawthorn, and the pastoral eglantine; 
Fast fading violets cover'd up in leaves; 
And mid-May's eldest child, 
The coming musk-rose, full of dewy wine, 

The murmurous haunt of flies on summer eves. 

Darkling I listen; and, for many a time 

I have been half in love with easeful Death, 
Call'd him soft names in many a mused rhyme, 

To take into the air my quiet breath; 
Now more than ever seems it rich to die. 
To cease upon the midnight with no pain, 

While thou art pouring forth thy soul abroad 
In such an ecstasy! 
Still wouldst thou sing, and I have ears in vain — 
To thy high requiem become a sod. 

Thou wast not born for death, immortal Bird! 

No hungry generations tread thee down; 
The voice I hear this passing night was heard 

In ancient days by emperor and clown: 
Perhaps the self-same song that found a path 

Through the sad heart of Ruth, when, sick for home, 
She stood in tears amid the alien corn; 
The same that oft-times hath 
Charm'd magic casements, opening on the foam 
Of perilous seas, in faery lands forlorn. 

Forlorn! the very word is like a bell 

To toll me back from thee to my sole self! 
Adieu! the fancy cannot cheat so well 
As she is fam'd to do, deceiving elf. 
Adieu! adieu! thy plaintive anthem fades 

Past the near meadows, over the still stream. 
Up the hill-side; and now 'tis buried deep 
In the next valley-glades: 
Was it a vision, or a waking dream? 

Fled is that music: — Do I wake or sleep? 

Winter 1997 


Easeful Death: 
From Keats to 

by Sissela Bok 

Darkling I listen; and, for many a time 

I have been half in love with easeful 

CaWd him soft names in many a mused 

To take into the air my quiet breath; 

Now more than ever seems it rich to die. 

To cease upon the midnight with no 


suicide and euthanasia that I took up 
in my doctoral dissertation in philoso- 
phy over a quarter of a century ago, in 
light of a state of affairs that I did not 
foresee at the time: that so many in 
our society should still have reason to 
fear the prospect of a dehumanizing, 
prolonged and painful death. But 
rather than rehearse the arguments for 
and against changes in the law, I sug- 
gest that we look, first, for some com- 
mon ground, some shared premises, 
from which we might examine the 
debates more fruitfully. 

I shall begin by considering the 
topic of easeful death, as illuminated 
by John Keats' "Ode to a Nightin- 

gale." Keats was 23 years old in May 
1 8 19 when he composed this poem. 
He had lived in the presence of illness 
and death since the age of eight, when 
an accident killed his father. He had 
nursed his mother, who died of con- 
sumption when he was 14. Shortly 
thereafter, he was apprenticed to a sur- 
geon and apothecary. At the time, sur- 
geons received training more 
rudimentary than that of physicians, 
which qualified them for such tasks as 
pulling teeth, providing general med- 
ical advice, and carrying out amputa- 

When he had finished his training, 
at 21, Keats decided to devote himself 
instead to poetry, no matter how 
unlikely he thought it would be to earn 
his living that way. That winter, he 
also nursed his younger brother, Tom, 
who was dying of consumption. 

"Ode to a Nightingale," written the 
following spring, conveys a longing to 
leave behind the sight and sounds of 
suffering and death that Keats himself 
knew so well: 

The weariness, the fever, and the fret 

Here, where men sit and hear each 
other groan; 

Where palsy shakes a few, sad, last gray 

Where youth grows pale, and spectre- 
thin, and dies 

Keats expresses the temptations of 
death in his own life, in part out of 
empathy for all who suffer, in part out 
of guilt to be still alive. But he had also 
discovered within himself the most 
exuberantly rich poetic genius, second, 
many say, only to Shakespeare. He 
conveys, too, the contradictions 
between longing for death and the 
passion to live and to create, between 
empathy for the the dying as against 
aching to escape, between heartache 
and ecstasy, between the intensity of 
life's experience and its brevity. 

These are tensions and countervail- 
ing forces we can all share when seeing 
death in others and thinking of our 
own lives and future death. But for the 
most part, we are masters at blocking 
these tensions out of our conscious- 
ness. Keats illuminates them all. He 
forces us to see the complexity, the 


Harvard Medical Alumni Bulletin 

warring impulses within ourselves, in 
their full energy and ability to pull us 
in several directions at once. As 
Professor Walter Jackson Bate says in 
his biography, Keats, the "Odes" are 
analogous to experience as a whole, 
which is why "we continue to return to 
them as we could not if they betrayed 
experience by oversimplifying it." 

Keats himself had worried about a 
recurring sore throat in 1819, even as 
he composed his great "Odes." That 
same fall, his condition worsened; 
fevers and hemorrhaging made him 
fear that he had developed consump- 
tion in its active phase. He wrote to a 
friend: "I wish for death every day and 
night to deliver me from these pains, 
and then I wish death away, for death 
would destroy even those pains which 
are better than nothing. Land and sea, 
weakness and decline are great separa- 
tors, but death is the great divorcer." 

Keats made one last great effort to 
live, to be cured. He decided to travel 
by steamer with his friend Joseph 
Severn to Italy, hoping that the milder 
climate would be beneficial and that a 
physician there of whom he had heard 
could help him to recover. Before they 
left England, Keats asked Severn to 
buy a bottle of laudanum (tincture of 
opium) for him. 

By the time they reached Rome, 
Keats was already close to death. His 
last months were spent in a small 
room, with next to no money, nursed 
by an increasingly desperate Severn 
and an ineffective physician. Keats 
asked Severn for the laudanum, hoping 
to use it, as in his poem, to drift into 
oblivion when his suffering grew too 
great. But Severn kept it from him. In 
a letter a month before Keats died, 
Severn wrote that the hardest point 
between them was: 

that cursed bottle of opium — he had 
detei-mhted on taking this the instant his 
recoveij should stop — he says to save him 
the extended miseij of a long illness — in 
his own mind he saw this fatal prospect — 
the dismal nights — the impossibility of 
receiving any sort of comfort — and above 
all the wasting of his body and helplessness 
— these he had determined on escaping — 
and but for me — he would have swal- 
lowed this draught 5 months since — 

Severn saw it as his Christian duty 
to keep the bottle from Keats. Many of 
us would have wished it otherwise, or 
would have wished for Keats to have 
that bottle as a way to still his pain, 
perhaps as a way toward "easeful 
death." When at last Keats knew that 
his death was imminent, he, who had 
seen so many die, asked Severn if he 
had ever had that experience. On hear- 
ing Severn reply that he had not, 
Keats's thoughts were with his friend 
more than with himself: "Well, then, I 
pity you poor Severn — what trouble 
and danger you have got into for me 
— now you must be firm, for it will 
not last long." The next day, February 
24, 182 1, Keats died, and his last hours 
were peaceful. 

Today's debates about physician- 
assisted suicide sometimes convey the 
false impression that most persons 
who are seriously ill, even in pain, 
nearing the end of life, want single- 
heartedly to achieve an easeful death 
and are only held back from finding 
such relief by society and its laws. The 
fact is, of course, that a great many are 
either vacillating, as was Keats, or 
wanting to live, as Keats did so fiercely 
much of the time; and that they see 
doctors and nurses and other health 
professionals who help them in this 
effort as their supporters, not their 

Olof Lagercrantz, a Swedish poet 
now in his mid-Bos, conveys this per- 
spective. Like Keats, he suffered from 
tuberculosis in his youth. Although he 
had been cured, the weakened condi- 
tion of his lungs made it necessary for 
him to be hospitalized whenever he 

experienced serious difficulty in 
breathing. In the following poem, 
written while in the hospital, 
Lagercrantz expresses a gratitude that 
I fully believe Keats would have 
shared, could he have received similar 

Lungorna ar vara inre vingar. 
The lungs are our inner wings. 

Med hjartat mellan sig de lyfter oss. 
With the heart between themselves they 
lift us. 

Nar deras fjaderandedrakter skadas 
When their feather breaths are hurt 

sjunker var flykt. — O, hjalp oss ni, 
our flight sinks. — 0, help us you, 

fortrogna med de faror som oss hotar, 
initiates of the dangers that threaten us, 

att halla oss i luften an en stund. 
to hold ourselves aloft yet awhile. 

Is there a shared premise that we 
can draw firom reflecting on both 
poems? At the very least, I suggest that 
it is the need for fuller perception of 
what is at issue when it comes to the 
approach of death; for encompassing 
greater complexity and depth than we 
encounter in many of today's debates 
about suicide, euthanasia and physi- 
cian-assisted suicide; for acknowledg- 
ing the pulls of different movements of 
the soul when it comes to death, ease- 
ful or otherwise; but also for seeing the 
strength of the hope, in the words of 
Lagercrantz, "to hold ourselves aloft 
yet awhile." This shared premise cau- 
tions us against "betraying experience 
by oversimplifying it," as Bate puts it. 
But it also underlines the attentive, 
supportive care that persons nearing 
death ought to have and too rarely 
receive, as well as the contrast between 
all that medicine can do today to cure 
disease and the everyday failures to 
provide humane care at the end of life. 

I did not fully foresee, in my 1970 

Winter 1997 


dissertation, tiiat tiiese failures would 
persist. At the time, I found commen- 
tators who either accepted both suicide 
and euthanasia as morally justified 
under certain circumstances or who 
rejected both as immoral; still others 
who distinguished between the two 
fi-om a moral point of view. According 
to the latter, there are extreme and 
tragic circumstances under which sui- 
cide should be seen as a legitimate 
option, whereas the risks of legalizing 
euthanasia are unacceptable. 

Though agreeing with this last 
group, I found the conflict to be sharp 
between the imderstandable individual 
calls for release from great and irreme- 
diable suffering and the legitimate 
importance that societies traditionally 
attach to protecting innocent third 
parties against risks resulting fi-om any 
relaxation, however well-intentioned, 
of rules against killing. 

What added to the poignancy of 
this conflict was that the arguments on 
each side were largely beside the point 
for those with most at stake on the 
other side. On the one hand, individu- 
als suffering so much as to plead for 
deliverance have done no harm to 
those hypothetical persons for whom 
they are being asked to make a sacri- 
fice; nor would their receiving volun- 
tary euthanasia direcdy harm any 
other person. Why, then, should they 
be forced to continue to suffer? On the 
other hand, those persons who might 
fall victim to errors and abuses result- 
ing from a societal shift in favor of vol- 
untary euthanasia would hardly accept 
the suffering of patients so desperate 
as to plead for euthanasia as a reason 
why their own interests should be sac- 
rificed, through no initiative of their 
own and without their consent. 

It was therefore not enough, I con- 
cluded, merely to take a position 
against legalizing euthanasia. 
Considering the individuals whose suf- 
fering leads them to plead for death, 
much more had to be done to respect 
their right to refuse treatment and 
even, as a last resort, their right to 
speed their own death. I supported liv- 

ing wills, still unfamiliar at the time, 
and urged greater stress on providing 
hvmiane care at the end of life, includ- 
ing adequate pain relief and the option 
of home care when possible when 
death was near. In Britain, Cicely 
Saunders, MD, had recentiy pioneered 
what was to become a growing hospice 
movement, stressing the personal 
attention, support, and provision of 
adequate pain relief and palliative care 
too often lacking in hospitals. 

In 1970, even as I did not anticipate 
the continued massive failure to pro- 
vide adequate relief and humane care 
at the end of life, so too I could not 
foresee that it would add so greatiy to 
the force of euthanasia advocacy. Least 
of all could I have foretold the appeal, 
for many in the public, of Jack 
Kevorkian's dramatic advocacy and 
implementation of what he calls 
"patholysis" to bring about death. His 
methods have brought renewed atten- 
tion on all sides of the debate about 
physician-aided suicide, to distinctions 
he expressly does not wish to draw, 
such as those between patients who are 
and are not in acute pain or suffering 
from a terminal illness. 

The current debate has also been 
galvanized by greater media coverage 
of the plight of many whom our med- 
ical care system are failing as they near 
the end of their lives. By now, even as 
life expectancy has increased and as old 
age has become a time of health and 
well-being for far more persons than 
had been expected even a decade ago, 
we have stark evidence of the extreme 
suffering that too many endure in our 
society at the end of life. We have 
learned that living wills and health 
care proxies often fail to provide ade- 
quate protection for patient choice, 
and that a high proportion of termi- 
nally ill patients are left without ade- 
quate information about their 
condition, and forced to suffer need- 
less pain before dying. The rights to 
refuse treatment and to be adequately 
informed may be guaranteed in the law 
and encoded in elegant statements of 
patients' rights; but they are worthless 

to any patient who cannot count upon 
them in practice. 

A study pubhshed in the fall of 
1995 has brought home the discrep- 
ancy between how patients at the end 
of life ought to be treated and how too 
many are in fact treated. The SUPPORT 
project ("Study to Understand 
Prognoses and Preferences for 
Outcomes and Risks of Treatments") 
was conducted in five major medical 
centers in this country. An editorial in 
the November 22/29, ^995 issue of the 
Journal of the American Medical 
Association points out that the SUPPORT 
study documented serious problems 
with terminal care, even after nurses 
relayed patients' wishes for treatment 
to doctors. Patients in the study expe- 
rienced considerable pain, and com- 
munication between physicians and 
patients was poor: 

Only ^i percent of patients in the study 
reported talking to their physicians about 
prognosis or about cardiopulfnonary resus- 
citation (cpr). Physicians misunderstood 
patients'' preferences regarding CPR in 80 
percent of the cases. Furthermore, physi- 
cians did not implement patients'' refusals 
of interventions. When patients wanted 
CPR withheld, a do not resuscitate (dnr) 
order was never written in about 50 per- 
cent of the cases. 

Behind these factual statements lie 
many thousands of individual human 
tragedies. The coauthors concluded 
that the picture they gave of the care 
of seriously ill or dying persons was 
not attractive, and that "One would 
certainly prefer to envision that, when 
confronted vdth life-threatening ill- 
ness, the patient and family would be 
included in discussions. Realistic esti- 
mates of outcome would be valued, 
pain would be treated, and dying 
would not be prolonged. That is still a 
worthy vision." 

One of the coleaders of the study, 
William Knaus, MD put the matter 
more blundy still in an interview with 
the Boston Globe: "When people die 
after prolonged suffering, the doctors 

Harvard Medical Alumni Bulletin 

say, 'We did everything we could.' 
They don't say, 'We put this person 
through hell before he died." 

The SUPPORT study ought to sound 
an alarm to all with a stake in the med- 
ical care given at the end of life. It 
should alert everyone to do much 
more than place faith in living wills, 
written directives and conversations 
with family members and health pro- 
fessionals. They should also look for 
available advance care planning, pallia- 
tive care and hospice alternatives. 

To those of us who have worked 
and written and taught in the field of 
medical ethics, the SUPPORT study 
must soimd the sharpest of alarms. Its 
results strike at the heart of what we 
have hoped to accomplish over the 
past decades on the subject of care for 
the dying. We have to ask ourselves 
how we can do better and reconsider 
our role in trying to counter the pre- 
sent systemic malfunctioning. True, it 
is still the case that the vast majority of 
physicians never had a course in med- 
ical ethics and were trained in a tradi- 
tion that placed less emphasis on 
shared decision-making with patients 
and their families; but this hardly suf- 
fices to explain the broad failure to 
abide by the most elementary tenets of 
good doctoring and legal obligation. 
The challenge for all who teach med- 
ical ethics will be to consider not only 
the courses but also the role models, 
the incentive structures and the insti- 
tutional policies that might promote 
and reinforce the more consistent hon- 
oring of these tenets. 

The medical profession as a whole, 
including hospital administrators and 
personnel, likewise have reason to look 
at the SUPPORT study as a wake-up call. 
Committees and groups are now con- 
sidering interventions more likely to 
bring about change than those found 
ineffective in the survey. Programs in 
palliative care and forms of collabora- 
tion with hospice programs are at last 
receiving more widespread attention. 
This is all to the good. But far more 
immediate action is also needed in 
hospitals, for the sake of patients 

already in the critical predicament 
described in the SUPPORT study. It is 
urgent that not a single patient should 
be placed at risk of suffering needlessly 
when death approaches by having his 
or her refusal of particular treatments 
ignored, or by being denied adequate 
pain relief. 

On these scores, both proponents 
and opponents of euthanasia and 
physician-assisted suicide can surely 
collaborate in pressing for more con- 
scientious honoring of existing guide- 
lines and laws, affecting far more 
individuals than those who desire to 
have their lives ended. On both sides 
of the debates, participants have rea- 
son to ask why more is not done for 
patients nearing death in our own soci- 
ety, one of the richest in the world, 
with many superbly trained health 
professionals capable of delivering the 
most expert medical care. 

On both sides, moreover, caution is 
surely warranted when it comes to 
reliance on laws, new or old, to ensure 
humane care at the end of life. 
Looking back at my conclusions in 
1970, 1 find that more Americans are 
now aware of the risks they confront 
unless they can opt for treatment 
through hospice and palliative care 
programs. Polls show that the great 
majority would prefer these, were they 
available, to any form of suicide or 

I find, too, that the risks we will run 
if we legalize the forms of physician- 
assisted suicide now under considera- 
tion in the courts are stronger in our 
society than when I first wrote. 
Domestic violence and elder abuse 
have increased. The financial pressures 
on famihes and the inequities related 
to medical care are greater. Our health 
care system is undergoing shifts pro- 
viding powerful incentives to minimize 
costs without, as yet, clear evidence 
that the interests of the most vulnera- 
ble are adequately protected. Physician 
impairment has been documented as 
more serious, more common and more 
persistent than was known earlier. And 
the levels of trust between health pro- 

fessionals and consumers have dimin- 

Given these conditions, our society 
is hardly an ideal one in which to 
experiment with legalizing euthanasia 
or physician-assisted suicide. Our first 
priorities must be to protect existing 
rights of patients, to collaborate with 
the many who struggle to wipe out the 
worst and most inhumane maltreat- 
ment, and to improve and cultivate the 
best forms of humane treatment at the 
end of hfe.^ 

Sissela Bok, PhD is a Distinguished Fellow 
in the Harvard Center for Population and 
Development Studies, and a former pro- 
fessor of philosophy at Brandeis University. 
This is excerpted from two lectures: the 
George W. Gay Lecture on Medical Ethics 
at Harvard Medical School, May 21, 
igg6 and the October 28, ipc)6 Castle 
Lecture at Yale University. 

Winter 1997 


Beds of Death, fivm The Disasters of War 
Francisco Jose de Goya y Lucientes — 
1 746- 1 828, 195 1 Purchase Fund, 
courtesy, Museum of Fine Arts, Boston 


Harvard Medical Alumni Bulletin 

on the 

hy James J. O^Connell 

Just after midnight on July 4th 
the outreach van workers and I were 
stunned by the makeshift memorial 
near Jack Anderson's park bench in 
Commonwealth Park near Kenmore 
Square. A rose had been tacked to a 
nearby tree, along with a picture of 
Jack, just above an arresting image of a 
grizzly bear on a card inscribed by 
street friends and neighbors, including 
the children who play in the park. 

Jack Anderson, known to all of us 
as "Bear," had been found dead next to 
his bench a few days earlier. He and 
Indian Jimmy had suffered head 
trauma and rib fractures in a car acci- 
dent in early June, and both had been 
sent from the hospital to recuperate at 
the Barbara Mclnnis House near 
Eggleston Square, our 50-bed sub- 
acute care facility that serves as an 
alternative to hospitalization for 
homeless men and women. A week 
before his death he absconded and 
found his way back to his makeshift 
home in the park. When we brought 
him soup and sandwiches late the next 
night, he politely resisted all entreaties 
and bribes to return to Mclnnis House 
or one of the shelters. The whiskey 
had restored his familiar boisterous 
laugh and gruff demeanor, and he 
proudly growled that he was "back in 
the lair where I belong." 

Jack had wandered Kenmore 
Square and Back Bay with a pack of 
insouciant postmodern exiles, charac- 
ters with local color worthy of Bret 
Harte's Goldrush campfires, scornful of 
traditional society and barely surviving 
at its cruel and bitter fringes. I've spent 
many nights over the past decade 
working on Pine Street Inn's Outreach 
Van, a literal lifeline of soup and sand- 
wiches and blankets to these fiercely 
independent individuals who sleep in 
the streets and parks, on fire escapes 
and grates, imder bridges and high- 
ways, and near the banks of Boston's 
Muddy and Charles rivers. 

They view their ostracism with bib- 
lical nobility, angrily acknowledging 
their banishment to wander the urban 
desert as prophets unfettered by mate- 
rial possessions and shunned by their 
own families and people. Many street 
names echo this theme: Simon the 
Elder, Isaiah with AIDS, Matthew Zion, 
Ezekiel from Cuba. The eccentricities 
are spellbinding, much like "the sub- 
terranean . . . the twilit characters of 
the metropoHs" in Joseph Mitchell's 
Up in the Old Hotel. No doubt Joe 
Gould, the drinker struggling to com- 
plete his translation of Longfellow's 
poetry into the language of seagulls 
while awaiting the publication of his 
magnum opus, "An Oral History of 
Our Time," spent his share of nights 
sleeping in Boston Common. 

I'm not sure how or when Jack 
Anderson came to be called Bear; 
some thought it went back to his days 
in the U.S. Marine Corps, others sus- 
pected a self-chosen sobriquet to pro- 
tect the shroud of mystery 
surrounding his life. Whatever the ori- 
gin, the ursine myth was embellished 
with characteristic aplomb. A thick 
red-brown beard matched his burly 
persona, while he often boasted of 
"hibernating" on the Boston 
University grates during the coldest 
winters and subsisting on garbage raids 
along the Back Bay alleys. A no-holes- 
barred street brawler, Bear had innu- 
merable visits to the emergency 
departments of Boston City and 

Massachusetts General Hospitals for 
stab wounds and head trauma, where 
he alternately charmed and exasper- 
ated his caregivers with his laughter 
and cockiness. 

Bear always claimed Denmark as 
his birthplace in 1963, and some "good 
and loving folks" had adopted and 
raised him near Norwich, 
Connecticut. He spoke of a stint in 
Norwich State Hospital when he was 
17 "for violent tendencies." Drinking 
and disorderly conduct resulted in a 
dishonorable discharge from his 
beloved Marines, and he survived by 
working as a bouncer, construction 
laborer and security officer. Jack 
Anderson was not his original name, 
but rather his proud and not-too-sub- 
tle American version of Hans 
Christian Andersen. His life was leg- 
endary on the streets, but hardly a 
fairy tale. 

We never found that original name, 
and Bear's body still lies unclaimed in 
the city morgue. In a few weeks, if no 
relatives come forward, the medical 
examiner will release him for burial in 
the pauper's cemetery alongside 
countless other homeless men and 
women who have died on Boston's 

Death is a quirky but steadfast pres- 
ence in the shelters and on the streets; 
over 700 of our patients have died 
since we began the Boston Health 
Care for the Homeless Program 
almost a dozen years ago, a staggering 
number for any general medical prac- 
tice that cares for 6,000 people each 
year. The litany of causes is legion and 
complex: exposure to the extremes of 
weather and temperature; the spread 
of communicable diseases, such as 
tuberculosis and pneumonia, in 
crowded shelters with inadequate ven- 
tilation; neglected chronic illnesses; 
horrifying violence; the high fre- 
quency of co-morbid medical and psy- 
chiatric illnesses; the ravages of 
substance abuse; inadequate nutrition, 
to name only a few. Homeless individ- 
uals and families are the most impov- 
erished of our urban poor, and suffer 

Winter 1997 

Jack Anderson memorial 

all the well-described health risks 
attendant to persistent abject poverty. 

Boston's shelters traditionally hold 
a service for each deceased guest, with 
a funeral and burial arranged when no 
family can be located. The services are 
profoundly moving, attended by staff, 
friends, and other shelter guests. 
Forgotten souls, weary pilgrims of 
America's streets and alleys, forsaken 
by reason or sobriety or luck, are 
afforded the dignity of a memorial ser- 
vice, a belated chance to be recognized 
and appreciated, and a final permanent 
resting place of one's own. Unruly 
drinkers and unkempt street-dwellers 
wash, shave and don suits and jackets 
gathered from the clothing rooms to 
attend a service in honor of one of 
their own. Proud pallbearers are cho- 
sen, and guests are transported by van 
to the church and the graveyard. Tears 
flow from places long fallow, while the 
presence of death becomes a gentle 
and almost soothing reminder of the 
ultimate equality and destiny of 

Four hundred people attended Joe 
Daley's funeral at Christ the King 
Church in Woburn in May of 1988. 
Joe had been a drinker for as long as 
anyone could remember. Three packs 
of cigarettes a day for over 40 years 
had probably caused the lung cancer 
we diagnosed about six months before 
his death. He had come to see me at 
our Boston City Hospital clinic after 
he had lost over 30 pounds, and 
explained that he had his "usual hack- 
ing cough" but could not eat or sleep. 
A chest x-ray showed that his right 
lung was filled with fluid, and only 
then did he admit to me that for 
months he had been barely able to 
breathe when he lay down to sleep at 

We drained several liters of bloody 
fluid from his lung, and he called me a 
hero after he slept soundly for eight 
hours that night. But the cytology 
showed malignant cells. Two weeks 
was about all he could tolerate in the 
hospital, pleading all the while to go 
back to the familiar surroundings of 

Harvard Medical Alumni Bulletin 

Pine Street Inn. He worked on the 
live-in staff, sorting donations to the 
clothing room and helping out in the 
kitchen, and shared a room in the 
tower with Eddie Sweeney, another 
feisty South Boston Irishman and, like 
Joe, a veteran of the Korean War. 

The prognosis was guarded, proba- 
bly several months at best. After our 
discussions with the oncologists and 
Joe, the staff at Pine Street allowed 
him to return for hospice care. Joe was 
able to work several hours a day when 
he returned, and he came to the 
nurses' clinic for medications several 
times each day. 

After five good months, he became 
too feeble to get out of his chair. The 
live-in staff brought meals to him, and 
the nurses volunteered to sit through 
the nights with him. The pleural effu- 
sion had begun to accumulate again, 
and Joe was becoming more short of 
breath. The cancer had spread to his 
bones and liver, and his intense pain 
required increasing doses of morphine. 

Peggy Thornton paged me just 
before midnight one Friday in May 
to let me know that he had stopped 
breathing. I had been sharing stories at 
Doyle's Pub in Jamaica Plain with 
Barbara Mclnnis, a heroine of mine 
who was one of the original clinic 
nurses at Pine Street Inn (and after 
whom we later named our respite 
facility), and we drove to the Inn to 
officially pronounce him. Joe had 
spent a peaceful day, and Peggy said he 
simply went quietly to sleep. Bill 
Mulrenan — a remarkable volunteer at 
the Catholic Worker's Haley House in 
the South End who had befriended Joe 
many years ago and invited him to hol- 
iday meals with his family — drove in 
from Woburn, having already notified 
the funeral home. Lauretta Woods, 
the supervisor of the live-in staff who 
had so staunchly supported Joe, came 
immediately from her home in Revere. 
Donna Scarpa, the clinic's head nurse 
who had provided much of the energy 
required to care for a dying person in a 
shelter setting, rushed over from her 
home near Worcester Square. 

Unruly drinkers 
and unkempt 
street-dwellers wash^ 
shave and don suits 
to honor one of 
their own. 

I remember sitting with this 
exhausted and devastated group, mar- 
velling at the obscurity in which they 
accomplished these quiet miracles. Six 
months ago Joe Daley had been fright- 
ened and alone, fully cognizant of the 
imminent end of a life he had botched. 
Bill and the shelter staff allowed him 
to orchestrate his own death on his 
own terms, and Joe died a peaceful and 
unbroken man. 

Most of the other deaths have been 
far from peaceful, and I would like to 
share a few of these experiences. 

Loretta B. stopped by the clinic one 
morning strung out on heroin and 
seeking a detox bed. No methadone 
beds would be available for a week, 
and she had no choice but to tough it 
out or keep using drugs until then. She 
was dismayed and fearful that she did 
not have the strength to steal or turn 
enough tricks, and she had "tons of 
debt and a slew of enemies out there." 
Loretta brought the Boston Herald arti- 
cle detailing the discovery of her 
friend Dawn Ruffin's decayed body in 
a Rockport dumpster. She had been 
with Dawn the night she stole money 
from her pimp, and he had publicly 
punished her in front of Loretta and 
two others by amputating her right 
arm with a machete, removing the 
only part of her body that had accessi- 
ble veins. No one was ever charged 
with the murder. "Drugs," moaned an 
inebriated Loretta, "are very scary 

Arthur H. had been coming inter- 
mittently to the clinic for many years, 
usually after taking a "header." Arthur 
was in his early 40s, learned, articulate 
and provocative, an observant chroni- 
cler of wasted lives and falls from 
grace, and a self-proclaimed "drunk 
and bum." His pleasant smile usually 
accompanied a blackened eye and vari- 
ably-placed facial sutures. While his 
imposing 6-foot-5-inch frame under- 
scored his patrician manner, the 
"headers" were actually withdrawal 
seizures, and I still cringe at the mem- 
ory of his skull cracking against the 
sidewalk after the rigid fall from that 

Usually very private about himself, 
Arthur was agitated when he came to 
the clinic in September of 1989, and it 
was to be the last time I saw him."I 
slept on a cot last night, the last one in 
line, next to the wall and just under the 
clock and the television set," he told 
me. "When I woke up this morning, 
the young fellow next to me was dead, 
apparently of internal bleeding. He 
was brought in by the cops and the 
EMTs in the middle of the night and 
dumped in the cot next to me, 2 2 years 
old. His name was Paul, and he had 
liver problems. Now I've never seen 
ambulances bring people to the shelter 
before, and I thought that very strange 
indeed. As you might imagine, I've 
seen hundreds of ambulances come to 
take people away, but I've never before 
seen them bring people to the shelter. 
Tragic. But I'm used to tragedy. I 
never met the guy other than in his 
final respose!" 

Arthur became exasperated, let me 
renew his blood pressure medication, 
and stormed off into the New England 
autumn. Two mornings later he was 
found bludgeoned to death a few 
blocks from the shelter, identified only 
by his fingerprints. 

Louie S. had first come to see me in 
1986, shortly after discovering that he 
had tested positive for Hrv' antibodies. 
After graduating from a nearby high 
school as a three-letter star athlete, he 
joined the army during the Vietnam 

Winter 1997 


"/'m slowly coming 
to grips with who 
I am^ and I know 
clearly that Fve 
just been along 
for the ride all 
these years,^^-Lomt 

era. To his chagrin he was given a tour 
in Spain and saw neither action nor 
Southeast Asia, but still was introduced 
to intravenous drugs, escalating rapidly 
to a $200 to $300 per day heroin habit. 
He lost interest in all else for the next 
17 years. 

Ruggedly handsome and an impos- 
ing 6*4", Louie was an Irish charmer 
and one of five children. In the mid- 
1970S, after failing to reconcile with 
his family, he retaliated by taking a 
shotgun and firing point blank into his 
abdomen, splattering his spleen and 
perforating his small intestine. As he 
sheepishly admitted, he never wanted 
to kill himself, but rather just mutilate 
and maim. 

A younger sister had been his clos- 
est friend, and in some contorted ges- 
ture to help her escape a failing 
marriage, he introduced her to heroin 
and life on the streets. Several years 
later she was found raped and killed in 
a back alley of the Combat Zone. The 
killer was an escapee from a psychiatric 
institution. Louie never recovered 
from that loss, and saw himself forever 
guilty of that murder. We had spoken 
many times about this, and I recall the 
unspeakable horror in his eyes as he 
pulled a tattered Boston Herald from his 
pocket and cursed himself and all the 
world for the prurient headlines eulo- 
gizing his beloved sister: "24- Year-Old 
Prostitute Killed in Zone. Naked 

Victim Found Raped and Strangled in 

Louie headed to the streets and 
quickly got himself arrested after 
shoplifting several bottles of Tylenol, 
worth $2 to $3 each on the street. 
Louie had explained to me some time 
ago how one could support a large 
heroin habit by shoplifting innocuous 
items worth less than $50 in total, 
assuring only a misdemeanor if caught. 
The following morning he was found 
in his cell hanging by his belt, cyanotic 
but still breathing. Rushed to the hos- 
pital, he suffered a respiratory arrest 
en route and was successfully resusci- 
tated in the emergency room. After a 
week in the ICU, he was transferred to 
a psychiatric facility. Upon discharge, 
he came directly to see me in the hos- 
pital clinic. He appeared exhausted 
and cachectic, but his mind was char- 
acteristically sharp and incisive. 

"It's just too much. This god- 
damned death sentence is just too 
much to handle. I have no family, my 
friends have deserted me, I can't even 
sleep with my girlfriend without think- 
ing I'm about to kill her. I've been 
cursed all my life and now the curse is 
literally running through my blood. 
I'm addicted to drugs, and I now real- 
ize I'll never shake it.. .but then again, 
why should I now? But it's funny, I'm 
slowly coming to grips with who I am, 
and I know clearly that I've just been 
along for the ride all these years. I've 
never contributed anything. I've never 
taken control of anything in my life." 

While Louie had not shown any 
signs or symptoms, he had been told 
that without his spleen the risk of pro- 
gressing to clinical AIDS was greater. 
And he was keenly aware that he had 
destroyed his own spleen with a shot- 
gun blast, almost in prophetic prepara- 
tion for the virus through which 
reputation and salvation would be 
wrought. The writing was on the wall. 

"The only war I've ever waged has 
been against my own body and my 
own cursed genes, and I've done a 
damn good job. All addicts have a 

death wish. We are all enslaved by our 
habits, and the thought that some virus 
hidden in our works might finally 
release us can be welcomed and 
embraced during those horrible 
moments of drug sickness before the 
next dose. But don't worry, Doc, I 
know that there's nothing you can 
offer, and I don't blame you a bit." He 
had me very worried. 

Three weeks later, on August 3 1 , 
Louie cashed his SSI check, left a note 
for his girlfi-iend, and injected enough 
heroin to end his war and declare a 
final peace. ^ 

James J. O'Connell is director of the 
Boston Health Care for the Homeless 
Program, which runs clinics for homeless 
persons at Boston Medical Center, 
Massachusetts General Hospital and over 
40 shelters in the Boston area. 


Harvard Medical Alumni Bulletin 

"Good Night, 
Willie Lee, 
ril See You in 
the Morning^^ 

by Alice Walker 

Looking down into my father's 

dead face 

for the last time 

my mother said without 

tears, without smiles 

without regrets 

but with civility 

"Good night, Willie Lee, I'll see you 

in the morning." 

And it was then I knew that the healing 

of all our wounds 

is forgiveness 

that permits a promise 

of our return 

at the end. 


''Good Night Willie Lee, III See You in 
the Morning, " copyiHght (c) ip'j^ by Alice 
Walker. From Good Night Willie Lee, 
I'll See You in the Morning by Alice 
Walker. Used by permission of Doiibleday, 
a division of Bantam Doubleday Dell 
Publishing Group, Inc. 

Give Me a Doctor 


Give me a doctor, partridge-plump. 
Short in the leg and broad in the rump. 
An endomorph with gentle hands. 
Who'll never make absurd demands 
That I abandon all my vices. 
Nor pull a long face in a crisis. 
But with a twinkle in his eye 
Will tell me that I have to die. 

POEMS by W.H. Auden. Copyright (c) 
IP76 by Edward Mendelson, William 
Meredith and Monroe K. Spears, executors of 
the Estate of W.H. Auden. Reprinted by per- 
mission of Random House, Inc. 


by George S. Bascom '52 

Understand — 

I'm running out of time for 

triviality and cleverness. 

Dying takes some thought. 

At night, lying behind closed lids 

and in the soft safe comfort 

of the bed and God, 

I find a peace that seems 

to lead on toward timelessness; 

toward — can it be so? — a state 

where space and eons do not matter, 

where the beginning and the end 

are close as now 

and part of it. 

Copyright 199^. Published by Sunflower 
University Press, i^^i Yuma, 
Manhattan, KS 66^0^-ioop. Used by 

Winter 1997 


The Death of Socrates 
Jacques Louis David — 1748-182 5 
The Metropolitan Museum of Art, 
Catharine Lorillard Wolfe Collection, 
Wolfe Fund, 1931. 


Harvard Medical Alumni Bulletin 

Risky and 
Nonrisky Acts 

by Sidney H. Wanzer 

Many persons equate physician 
assistance in dying with physician- 
assisted suicide or euthanasia and 
therefore assume that assistance in 
dying is legally or ethically risky for 
the providing physician. The most 
common form of assistance in dying is 
simply the provision of good medical 
care to a person who is at the end of 
life. This care is noncontroversial and 
free of risk, contrary to assisted suicide 
and euthanasia where risks are clearly 
present. Nevertheless, physician assis- 
tance in dying is beset with problems 
throughout the spectrum of treat- 
ment — with risks perceived in all areas. 
These perceived and actual risks can 
lead to physician inaction that is often 

Risk Free and Easy 
I have been impressed again and again 
that some actions that are the simplest, 
least controversial, and most free of 
risk are not used. This was brought 
home to me clearly a few months ago 
in the folloviring office visit. 

She was a charming woman in her 
mid-yos, obviously extremely devoted 
to her husband, who had suffered a 
very bad stroke last year. She spoke of 
him lovingly and gendy. Her son 
accompanied her to my office and I 
was instantly won over by both of 
them. The husband must have been a 
wonderfol man to have such a wife and 

She had been referred by a col- 
league of mine who had called to ask 

to whom in the community he could 
refer them for a discussion about their 
options at the end of her husband's 
life. For many months he had been 
unable to speak. Communication was 
reduced to questionably meaningful 
nods of the head or looks. He choked 
on food and water, and was fed via a 
gastrostomy tube. He had had 
repeated aspiration pneumonia that 
precipitated hospital admissions and 
antibiotics. There was a long list of 
many fine institutions he had been in, 
beginning with a tertiary center where 
he was on a respirator, ending with his 
present nursing home. No one doctor 
was clearly in charge. Whenever he 
had a threatening fever or respiratory 
difficulty, he would be hurried back to 
either an emergency room or hospital 
ward for aggressive treatment. He 
remained totally, completely and 
hopelessly disabled. 

She was confused as to what she 
should do. She had a properly exe- 
cuted medical proxy that gave her 
complete authority to speak in his 
behalf, but she did not really under- 
stand that power. She was distressed at 
his predicament and felt desperately 
that something needed to be done. 

We talked for an hour, and I gave 
her my thoughts. As they left, both 
expressed profound appreciation for 
what I had told them and said that no 
one had ever spoken to them about 
those suggestions. They left with new 
resolve to address his predicament in a 
different way, and they seemed 

relieved and somewhat encouraged. 

What had I told them? I discussed 
what to me were simple concepts and 
plans of action, yet things they did not 

• Do not feel guilty about a firm 
decision to render comfort care only. 
He is not going to die from your say- 
ing no to forther aggressive interven- 
tion. He is dying from his stroke. 

• It is acceptable to stop unwanted 
treatment. There is no difference 
between stopping a treatment and not 
having started it in the first place. 

• Define who is in charge. It should 
be one doctor. 

• "Do not resuscitate" orders are 

• The proper dose of pain medica- 
tion is the dose that relieves pain, even 
if this were to shorten life. 

• The patient, the ultimate authority 
as to what is to be done, is now 
included in the medical decision-mak- 
ing process in a meaningful way that 
never used to occur in the era of the 
paternalistic physician. If the patient 
cannot participate in medical decision- 
making, a duly designated agent has 
that power. 

• It is appropriate for both patient (or 
agent) and caretakers at some point to 
adopt a goal that states that the aim in 
care is not to restore health, but to 
give comfort only, and to assist the 
patient in the dying process. 

• Above all else, define the goals of 

In the last ten to fifteen years pre- 

WiNTER 1997 


cepts and actions have developed that 
are legally and ethically possible in 
assisting a dying patient. These are all 
now noncontroversial, and my state- 
ments to the family represented some 
of these concepts. This family had rel- 
atively easy needs that could be satis- 
fied by these precepts, yet they were 
unaware of what could be done 
because no one had sat down with 
them to discuss the possibilities. Not 
one of these options was controversial 
or legally risky, and assisted suicide or 
euthanasia was never mentioned. The 
principal thing lacking was definition 
of the goal. 

This story reflects a gap between 
what we say is all right to do and what 
we actually do. This gap is a major 
problem that too often stands in the 
way of a peaceful death, a conclusion 
that was dramatized recently by a 
Robert Woods Johnson study that 
highlighted the failure of many physi- 
cians to provide adequate comfort care 
for the dying. 

The Perception of Risk 
For the physician there are no risks 
associated with implementing the 
actions I suggested, yet the fact that no 
one had reviewed them with the family 
suggests that the caregivers perceived 
some risks. These perceived risks may 
lead to inaction by the physician due 
to fear of the consequences, and need- 
less suffering by the patient and family. 
These perceived risks include: 

• / may he aitidzed by my colleagues or 
family for not pushing ahead. This is 
never a problem if the goal of assisting 
in dying is carefully defined. 

• 7 may he criticized for not pushing for 
treatment aimed at restoration of health. 
We should base our actions on what is 
likely to happen and not strive for out- 
comes that have littie chance of suc- 
cess. We should act on probabilities. 

• 1 may he sued for withdrawing life- 
prolonging measures or not initiating 
treatment for pneumonia. This is never a 
problem in a dying patient when the 
goal is defined and agreed upon. 

• / fnay be criticized for not giving suffi- 
cient fluids to alleviate thirst. This is not 

a problem in the dying patient, con- 
trary to what many believe. 

Most lawyers would agree that the 
risks when dealing with these ques- 
tions are nonexistent for the physician 
when good medicine is practiced in 
good faith, the problem is clear, a 
competent patient or agent has agreed, 
the physician acts at the behest of the 
patient and negligence is absent. The 
safest legal route for the physician is 
simply what is best medically for the 

The Riskier End of Spectrum 
More risk for the physician does arise 
as one moves toward the assisted sui- 
cide end of the spectrum of care. 
These risks should be rare, however, 
since physician-assisted suicide itself 
should be rare if the care of the dying 
patient is ideal. A reasonably peaceful 
dying should be possible if the physi- 
cian offers meticulous attention to 
details of comfort care, assurances that 
the patient will not be abandoned, 
truly effective pain relief, and strong 
psychosocial support. 

for the End 

Physician-assisted suicide is a 
thorny issue within the medical 
community, one that generates 
strong feelings on both sides of 
the aisle. Linda Emanuel '84 
found herself in the midst of 
the debate when she took a 
two-year leave of absence from 
HMS to launch the Ethics 
Institute at the American 
Medical Association and serve 
as the AMA's vice president for 
ethics standards. 

Although Emanuel, HMS assis- 
tant professor of medicine and 
social medicine and assistant 
director of the HMS division of 
medical ethics, has a new job, 
her research has focused on 
end-of-life issues for the last 
ten years. Specifically, 
Emanuel has written on 
advance care planning, a 

process whereby patients make 
decisions about what medical 
care they would want if faced 
with a life-threatening illness 
or injury. This is done with the 
patient's doctor and surro- 
gate — the person designated 
by the patient to make deci- 
sions when the patient no 
longer can. The patient, doctor 
and surrogate all sit down 
together to discuss and then 
document the patient's wishes. 
The result is an advance direc- 
tive, although not all people 
who have advance directives 
involve a surrogate or even 
their doctors. 

Advance directives have two 
components: documentation of 
a patient's wishes, or living 
will; and a designated decision- 
maker by proxy. Some states 

have a living will statute in 
addition to or instead of a 
health care proxy statute. Even 
in states with no living will 
statute, personal statements 
should be honored under con- 
stitutional law. 

To facilitate planning for end- 
of-life care, Emanuel has devel- 
oped a worksheet that outlines 
several end-of-life circum- 
stances a patient could face in 
the future. This validated work- 
sheet has been researched to 
ensure that it covers all rele- 
vant issues and framed so that 
responses automatically reflect 
patients' preferences. It is 
likely to get the same response 
if the patient is requestioned, 
and is applicable in the clinical 


Harvard Medical Alumni Bulletin 

However, in a few instances in 
one's career, a physician will be faced 
with the situation in which all of these 
measures have been attended to, and 
the patient still faces intolerable dis- 
tress and indignity, such that ending 
life becomes the best option and the 
proper treatment. I speak of this as a 
treatment, which in my opinion it is, 
but it is a treatment that may entail 
some actual risk for the physician. 

How much risk is associated with 
assisted suicide depends on what state 
one practices in, whether the act is 
public or private, what the attitudes of 
the local district attorneys are, and 
how much unanimity there is among 
the family and caregivers surrounding 
the patient. The amount of risk the 
physician can comfortably tolerate also 
enters the equation. These variables 
obviously lead to many possible sce- 

It is hard to categorize precisely the 
legal situation in the various states, but 
Hemlock Society USA estimates there 
are 34 states in which assisted suicide 
is criminalized by statute, ten in which 

The safest legal route 
for the physician is 
simply what is best 
medically for the 

it is a criminal act by common law, five 
in which it is unclear, and one in 
which physician-assisted suicide has 
been legalized but is being challenged 
in court. In states with no statutes on 
the books, case (common) law could be 
applied and a prosecutor might bring 
charges for assisting in suicide based 
on precedent from prior cases. The 
risk of this happening is hard to define 
and depends greatly on interpretation 
and the individual district attorney. If 
suicide is not a crime in a given state, 
then assisting in suicide cannot be, but 

the prosecutor might make a case for 
some form of homicide (probably 
involuntary manslaughter), citing reck- 
less behavior. 

Those who are not lawyers often 
feel there must be a legal justification 
for "mercy killing," but this is not so. 
Persons charged with mercy killing 
may not be convicted, but this is not 
for lack of law (it is illegal). Rather, 
prosecutors do not prosecute or juries 
do not convict (they identify with the 

In states without statutes against 
assisting in suicide, another avenue of 
charges could be through civil actions. 
Every state has a wrongful death 
statute that involves reckless actions or 
negligence and a noncriminal suit for 
damages might be filed, but practically 
speaking, this does not happen. Lastly, 
a person who feels aggrieved could 
bring complaints to the state medical 
society, requesting disciplinary actions. 
Again, this avenue is rarely used. 

How likely are these risks? They 
are very low if the physician acts in 
accordance with the wishes of a com- 

Going through the worksheet 
step by step and considering 
these potential scenarios is 
what Emanuel terms a "struc- 
tured deliberation." Through 
the years, Emanuel has seen 
that the deliberations serve 
more for the surrogate than 
the patient, since it will be the 
surrogate who will act on the 
patient's behalf. Although 
sometimes these preferences 
are overriden or ignored, no 
doctor has ever been sued for 
following a living will. 

Emanuel believes that advance 
care planning should be woven 
into routine clinical encounters 
and evolve over time, with the 
final document reviewed peri- 
odically by all the parties. She 
also thinks it should become 
standard in the physician/ 

patient encounter, like taking a 
patient's history. "I initiate this 
conversation at approximately 
the fifth routine visit with most 
of my patients, and then it 
becomes a routine matter to 
refer back to or update our 
plans for future care. I find it 
strengthens the patient/doctor 
alliance wonderfully." Ideally 
advance care planning should 
be initiated by the primary care 
doctor or whoever is at the 
center of the patient's health 
care team and should take 
place before serious illness or 
injury has occurred. 

Getting to the point of planning 
for death is not something that 
comes naturally to either doc- 
tors or patients— only 20 per- 
cent of people actually have 
advance directives. "We live in 

a death-denying culture. We 
have bought into the idea that 
we can triumph over death," 
says Emanuel. "We don't teach 
doctors how to talk about 
death or plan for it. The usual 
model of 'see one, do one, 
teach one' does not occur. 
Doctors have a special duty to 
put it right." 

"Putting it right" is both a goal 
of Emanuel's and the AMA's, 
which hopes to improve the 
rate of discussing and planning 
for end-of-life care through 
training programs for doctors 
across the country. With this 
training, every doctor would be 
skilled in advance care plan- 
ning and palliative care, as well 
as in recognizing depression, 
the treatment of which may 
prove to reduce the number of 

requests for assistance in 
dying by terminally ill patients. 
This was a conclusion from a 
study led by Emanuel's col- 
league (and husband) Ezekiel 
Emanuel '88, which showed 
that terminally ill patients who 
are depressed are more likely 
to ask for help in dying. 
Further research is necessary 
to confirm these results and 
determine if treating depres- 
sion would indeed have an 
impact on these requests. 

Emanuel notes that advance 
care planning is the backdrop 
for the current debate about 
physician-assisted suicide but 
states that it is a "false 
debate." "The real issues for 
patients concern controlling 
their pain, not being a burden 
to their family and not feeling 

Winter 1997 

petent patient, the family has been in 
support, and the act has been nonpub- 
Hc. There has never been a conviction 
of a physician for assisting in suicide 
when these conditions are met. When 
the act is not secret, risk increases, but 
still, only one physician has been con- 
victed. In one other well known 
instance involving a publicized act, 
Timothy Quill, an internist in 
Rochester, New York, was charged by 
the local district attorney, but the 
grand jury refused to indict. 

Covert Actions 
Regardless of the law in any given 
state, assisted suicide in this country 
currentiy entails little risk to the physi- 
cian if actions are private; however, 
that is a big "if." In order to be certain 
of no repercussions, the action must be 
strictly private, which can be difficult 
to ensure. 

Relying on secrecy to keep the 
physician out of trouble is risky in two 
ways. The attempt at secrecy may fail, 
and the opportunity for consultation 
and support from colleagues is not 

My brother never 
used the pills, but 
they were a great 
comfort to him. 

possible. The latter puts the physician 
in a more vulnerable position of acting 
unilaterally, without collegia! sup- 
port — always a more risky position. 
Both the patient and the physician can 
benefit from consultation and advice 
from other professionals. A law regu- 
lating physician-assisted suicide would 
solve these two problems. 

The Right Comfort Level 
In addition to the minimal legal risks 
of assisted suicide, there remains the 
risk of the physician having misgivings 
in retrospect. We have to live with 
what we do. I believe that this risk of 

conscience is very small if the situation 
demands the action in the first place. 
No assistance should be provided in 
the absence of a situation declaring 
itself positively, namely, there is 
absolutely no other way to avoid 
extreme suffering. 

Even so, the best of caregivers can 
have great pause before acceding to a 
request for assisted suicide. It is not a 
light request. I recall the ambivalence I 
felt in the instance of my older 
brother's death. About seven or eight 
years ago he was dying with metastatic 
carcinoma of the lung and I plarmed a 
goodbye trip to North CaroHna to see 
him. Several weeks before my planned 
visit, I sent him a draft copy of an arti- 
cle I had coauthored, oudining the 
proposition that assisting in suicide 
could, under certain circumstances, be 
an ethical act. 

He telephoned me to say urgently 
that that was what he wanted and 
asked if I would bring him some pills 
when I came. I said I would. When I 
walked into his bedroom a short time 
later, he was sitting bolt upright in 

abandoned. We should be 
improving quality care of the 
dying and access to it before 
considering assisted suicide as 
a legally and medically 
endorsed option. We have a 
long way to go still." 

Emanuel says that it is rare for 
doctors to be asked to assist in 
ending a life, with most only 
asked a handful of times dur- 
ing their entire careers. She 
personally has had two 
patients who asked her for help 
in dying. She responded by 
doing advance care planning 
with both patients, after which 
neither had the request. 
"Patients can refuse life-sus- 
taining intervention and have 
more control. They see this 
once they go through advance 
care planning." 

There is a lot on Emanuel's 
plate as she and the AMA set 
out to improve the quality of 
care of the dying and formally 
oppose physician-assisted sui- 
cide. A coalition of over 20 
local, state and national med- 
ical oi^anizations has been 
convened. In addition, the AMA 
petitioned the Supreme Court 
to consider reviewing the 2nd 
and 9th U.S. Circuit Courts of 
Appeals cases that declared 
state bans on physician- 
assisted suicide to be unconsti- 
tutional. The Supreme Court 
has agreed to take these 
cases, so the AMA will now 
submit a brief to persuade the 
court that physician-assisted 
suicide should not be consid- 
ered a constitutional right. 

Emanuel is immersed in an 
issue that has not just cap- 
tured the medical community's 
attention, but the general pub- 
lic's as well. This is in large 
part due to Jack Kevorkian, the 
former pathologist who is not 
camera-shy when it comes to 
his role in helping people com- 
mit suicide. 

"Kevorkian is using a much 
more controversial standard 
than most advocates of physi- 
cian-assisted suicide. His stan- 
dard is if people want it, they 
get it." Emanuel comments 
that one of Kevorkian's most 
publicized cases (involving a 
woman from Massachusetts 
who had depression and two 
nonfatal illnesses, fibromyalgia 
and chronic fatigue syndrome) 
demonstrates what can occur 

in the absence of legal and 
professional boundaries. "This 
can happen to vulnerable and 
disempowered groups. 
Kevorkian has killed two times 
as many women as men. What 
about patients who are silent, 
intimidated, fearful of a profes- 
sion that agrees to help 
depressed people die?" 

Emanuel observes that 
although the dilemma of physi- 
cian-assisted suicide has been 
around since before 
Hippocrates, it is once again 
time for the medical profession 
to articulate professional val- 
ues about it. Emanuel, who 
moved to the AMA's headquar- 
ters in Chicago with her hus- 
band (who commutes to his 
position at Dana-Farber Cancer 
Institute) and their three chil- 


Harvard Medical Alumni Bulletin 

bed, obviously in great distress due to 
uncontrolled pain. His very first words 
to me were not of greeting, but simply, 
"Did you bring the pills?" 

I was not certain of the law in 
North Carolina or of the reaction of 
his children (all adult) were they to 
know of this possible action of his and 
mine. His wife was in agreement with 
whatever he wanted, but she did not 
want their children involved in the 
decision. I was uneasy about not hav- 
ing the children's participation and felt 
there might be undefined legal risks to 
me since I did not know the law in 
North Carolina. These risks were 
probably small since no one else was 
involved other than my brother, his 
wife and me — it was not a public act. 
More important were the risks to my 
own personal ease. If he took the pills 
and the children were not involved, 
there could be psychological conse- 

As it turned out, the whole question 
was moot. Pain medication was 
upgraded drastically, pain control was 
estabhshed within the next 24 hours. 

dren, is sensitive to the com- 
plexity of tlie debate. 

"is pliysician-assisted suicide 
ever right?" Emanuel ponders 
out loud. "I can theoretically 
imagine intolerable suffering 
and imminent death, yet I have 
never seen a case of patient 
suffering that could not be 
handled by aggressive pallia- 
tive care. Loss of trust in the 
profession will become tangible 
if physician-assisted suicide 
becomes common." 

and my brother died reasonably peace- 
ful a week later. 

My brother never used the pills, 
but they were a great comfort to him. 
He kept them immediately at hand in 
his bedside table and they clearly gave 
him a sense of control, which made all 
the difference in the world. We were 
able to have a number of good conver- 
sations about life — and death — in that 

Those risks I courted were mostly 
perceived risks, not actual. 

Model Law for 
Physician-assisted Suicide 
Most of the problems at the riskier end 
of the spectrum of assistance could be 
avoided if these actions were regulated 
by law. We need to have the option of 
performing assisted suicide that is 
openly considered and guided by 
legally prescribed procedures, such 
that there are no perceived or actual 
risks to the physician or to the patient 
and family, as long as established 
guidelines are followed. A group of 
Boston physicians and lawyers recently 
published a model law that addresses 
this need (Baron CH et al. A model 
state act to authorize and regulate 
physician-assisted suicide. Harvard 
Journal on Legislation. 1996;33:1-34), 
and there is much interest and effort in 
other parts of this country and abroad. 
In Australia a recent statute has been 
enacted that permits physician-assisted 
suicide, and the first death under that 
statute just took place. 


The most commonly needed assistance 
the dying patient requires is physician 
coimselling about the available options 
for noncontroversial care, given in 
nonhurried conversation. This incurs 
no legal or psychological risk. Often 
these simplest options are not dis- 
cussed sufficiently and the patient 
remains poorly guided. 

In the very infrequent situation in 
which assisted suicide is the only 
answer for intolerable distress, the 
physician runs very littie legal risk if 
the assistance is given covertiy, but 
there are drawbacks to secrecy. Risks 
increase as the action becomes more 
public, but variably so, according to 
differing state law. 

Medically-assisted suicide is an 
option that needs to be available to 
patients for whom suffering cannot be 
relieved. This treatment needs to be 
recognized and guided by new state 
laws that will reduce legal and psycho- 
logical risk for both physician and 
patient. ^ 

Sidney H. Wanzer is clinical director 
of Harvard Law School Health Se?~vices. 
He would like to acknowledge Professor 
Charles Baron, Professor James 
Vorenberg, Professor Alan Stone, Mr. 
Sidney Rosojf and Ms. Helen Voorhis 
who kindly offered helpful suggestions 
and statistics. 

Janet Walzer 

Winter 1997 


Divine Personification of Death: The 
jackal-headed Egyptian god Anubis 
touches the soul of the man while the 
mummy on the left is the receptacle 
for the man's body (30BC-AD395). 
Louvre, Paris. 


Harvard Medical Alumni Bulletin 

A Good Death 

by Howard M. Spiro 

the spring of 1997, so I fear to test the 
irony of fate by writing about death or 
end-of-hfe decisions. Still, at the 
antipodes of Yale two years ago, a col- 
loquium, "Ars Moriendi," brought 
together physicians who treat dying 
people — the young who die too early 
from AIDS and the old who die too 
late — with theologians and historians, 
who can give death its context. That 
memorial service on the "ways of 
dying" has been collected in a new 
book, Facing Death — Where Religion, 
Culture and Medicine Meet. I am glad to 
relate some of what I have learned 
from putting together that conference 
and book. 

We all die, but doctors rarely talk 
about death. Each of us dies only once, 
and we get little chance to practice. 
Few modem Americans — vmlike their 
Puritan predecessors — prepare for that 
final episode. People live so much 
longer than before that death has 
come to seem a disease that can be 
indefinitely postponed, a denial con- 
firmed by the adoration for youth 
everywhere around us. The old or 
middle-aged so rarely appear in our 
magazines and television that one 
wonders what advertising might have 
done for Jonathan Edwards, and 
whether the "fiery pit" might have 
become an icon. Surrounded by 
images of the young in all their exu- 
berance, we almost never talk about 

Death was no stranger to the house 
staff of the old Peter Bent Brigham 
Hospital in the 1940s; when patients 
were lined up on either side of wards 
E- and F-main, drawn curtains told 
the story. Then, dying was usually 

short and merciful. Patients with a 
heart attack went quickly when all that 
we could do was inject epinephrine 
into the heart. More than once, I 
heard tell, plugs were pulled on the 
"iron lungs" that kept some polio 
patients breathing whom the doctors 
judged better off dead. 

"To cure sometimes, to care 
always" was our guide, as it has been to 
physicians for generations. The 
astounding development of science 
and technology that began in the 
1950s contorted those duties and 
turned caring into a very long battle 
against death. 

As the millennium rolls around, 
patients with heart trouble now leave 
our hospitals with coronary arteries 
braced open by stents or rearranged by 
surgery, to live happily much longer — 
and they die much later from less mer- 
ciful cancers or dementia. Improve- 
ments in public health and social con- 
ditions have also greatly widened the 
lives of the growing number of old 
people over 80. Last summer, my wife 
and I, who circle the further side of 70, 
took three 91 -year-old relatives out to 
lunch with no more sensation in the 
restaurant than if we had brought 
along three teenagers. 

In the fifties and sixties, doctors 
cared for the dying without the tradi- 
tional help of the clergy, partly 
because the clergy were abandoning 
the hospitals or taking on the ways of 
social workers or psychiatrists. They 
left to us the ethical questions that 
came from our powers as the newly 
minted "ethicists." As American medi- 
cine moved from being the province of 
an almost entirely white and Prot- 
estant middle class, the growing diver- 

sity of faces and opinions made discus- 
sion of end-of-life problems from a 
religious standpoint seem prejudiced. 

Yet many new issues need contem- 
plation. Along with the growing num- 
bers of the very old and dependent 
come a large number of infants born 
"prematurely," a term whose limits 
keep shrinking with new ways of pre- 
serving life. The growing number of 
patients with AIDS, with their at first 
unfathomable diseases, add to the 
medical dilemmas, while violence 
brings a new and dreadful plague. 

Our technology has forced people 
to give up the right to determine when 
and how they die. To die at home, face 
to the wall, to stop eating, is — modern 
science again confirms — a comfortable 
way to go, one still possible at home or 
hospice. But in the bright lights of the 
hospital, this personal decision 
"morphs" into the "decision-making 
process," which involves ethicists, 
medical care workers, lawyers and 

Hospitals are poor places to die, 
and even worse to mourn. My own 
institution sprawls over three huge 
buildings, but our chapel, so ecumeni- 
cal as to seem secular, takes up less 
than 20 by 20 feet. There is no place 
on our wards for people to pray or 
think in private. As death has moved 
from the home to the hospital, from 
clergy to doctors, families are kept far 
away behind barriers. 

The growing numbers of the slowly 
dying have forced discussion of 
euthanasia to the fore. Certain that 
doctors should never kill, many worry 
about why doctors are needed for 
euthanasia. Physicians who relieve 
patients in pain, even if it slows or 

Winter 1997 


stops their breathing, are not killers. 
Physicians may even help their 
patients choose the means and circum- 
stances of their final hours. But a doc- 
tor seems as unnecessary for the final 
act as for the execution of a criminal. 
Indeed, the ritual of swabbing the 
injection site before execution must be 
intended to simulate a medical act. 

Some take the position that things 
are okay as they are: doctors fearing 
prosecution do not unduly yield by 
prescribing soporifics to patients who 
want to kill themselves. Others, nurse 
practitioners prominent among them, 
argue that doctors usually do not know 
enough about their patients, let alone 
about death or dying, to make such 
decisions, and the 1995 SUPPORT study 
confirms that. Our major expertise 
often seems to be an ability to write 
the final prescription. 

Within limits, physicians can judge 
who is beyond help and who will soon 
die; beyond that, we physicians have 
attended too little to the humanities 
and to life — let alone death — to make 
such awesome final deliberations for 
others. Still, involved as we are in 
those final decisions, doctors must 
learn to understand death and dying, 
and that involves life and living, as 

Winnowed by academic success in 
high school, trained as scientists in 
college and medical school, inspired to 
action not reflection, physicians con- 
front death as defeat. We lack the 
intellectual background and the habits 
of reading and contemplation to con- 
front the new dying, once so swift and 
now so slow. The agonies of pro- 
longed dying might perplex us, but we 
rarely talk about such matters in our 
grand rounds or conferences. 

Our colloquium made clear how 
rarely nonmedical people now witness 
other people dying: a 50-year-old his- 
torian confessed that he had never 
seen a dead person, let alone someone 
dying. When death was common, 
Europeans and Americans had many 
children because most of them would 
die during childhood; then no one 

Our patients 
"expire^ " ''go down- 
hiir or they JaiF 
treatment^ they 
almost never die. 

needed a reawakening to death or an 
Ars Moriendi. Now that death is well 
hidden, lay people as well as physicians 
must reacquaint themselves with it. 

Death has gone from being a cere- 
mony in which everyone participated, 
because people died at home, a natural 
phenomenon familiar and acceptable 
even to children. For many in the 
West, death was no end but a door- 
way, "tame" Aries has called it. Now it 
is the "wild" death of technology when 
the dying patient is separated from 
family and friends by a crew of techni- 
cians and physicians, and dies alone, 
for all the hubbub. 

Physicians and nurses still know 
death and dying, but even for us death 
has replaced sex as the forbidden topic, 
mentioned largely in euphemisms. We 
doctors find the death of a patient a 
defeat, not a conclusion to life, and we 
seek roundabout comfort: our patients 
"expire," "go downhill" or they "fail" 
treatment, they almost never die. 
Memorable remarks that used to echo 
the deathbed scene are now muffled in 
hospitals by apparatus displacing the 
inevitable. Doctors need to be 
reminded that death can define a life, 
and may sometimes be welcome. 

Technology has made death a 
purely physical process; the decision 
that someone is "dead" has become a 
highly technical and sometimes con- 
tentious judgment, no longer of philo- 
sophical, cultural and religious 
concern, but simply a biological mat- 
ter. Our organs may go on living after 
we die. Where once pathologists eager 

for autopsies roamed the ward of the 
Brigham to read the records of those 
close to death, now I hear that trans- 
plant surgeons, or their agents eager 
for organs, search the wards for the 
"brain dead" to become "donors." 

Doctors ask why a patient has died 
and what they could have done to pre- 
vent that death, but they almost never 
wonder about a "good death." 
"Premeds" rarely take courses in his- 
tory, philosophy or the social studies 
that might enrich their understanding 
of death, and maybe even of life. In 
medical school they can dissect the 
body, but they cannot scan mind or 
spirit. What they cannot see, doctors 
do not yet treat. 

Death does define life; thinking 
about death helps us to think about 
what it is to be a person. To most doc- 
tors, dying means only the end of life. 
The loss of dignity, of a sense of 
humor, of wonder and imagination 
concern them far less. 

Philosophers may wrestle with the 
gradual blunting of Alzheimer's dis- 
ease; the mind for them is different 
from spirit and soul. For the religious, 
death remains a doorway; to talk of a 
terminal illness is to consider only the 
death of the body. Each culture 
imbues itself with different notions of 
death and dying, yet each person must 
die, finally, alone, each in his or her 
own way. 

The domains of death lie divided. 
Physicians and nurses who are the only 
ones with intimate experience of death 
and dying have little to do with clergy 
and historians, for they are too busy to 
meditate on what they have seen. 
Death needs no rebirth, but those sep- 
arate countries need reunification. 
With the help of theologians, histori- 
ans and the clergy, doctors and nurses 
could frame a meaning; the rituals of 
mourning, funerals, graveyards even, 
bear witness to humankind's many 
attempts to fashion that frame. Funeral 
directors also have much to tell physi- 
cians, who might even find the solace 
of a good death in attending more 
funerals than they do. 


Harvard Medical Alumni Bulletin 

We doctors read our journals for 
the latest medical advances, but we 
rarely read history. Genetics is our 
current hope, history as well as 
prophecy, but it looms far more 
important than any stories of the past, 
even when they are our own. A five- 
year-old medical journal is already 
archaic to doctors who lust after the 
very newest. In William Harvey or 
even in William Osier, we find jocose 
reminders of how far our understand- 
ing of biology and physiology has 
advanced. We rarely read and never 
discuss Shakespeare or Montaigne, 
Plato or the Bible (to pick examples 
from Western culture only) to find 
how changeless are the passions of 

In the medical intensive care units 
where the young care for the old, doc- 
tors and nurses are ill-prepared for the 
medical battles that they must fight. 
Sometimes among the older nurses 
and doctors a kind of nostalgia grows 
for the simpler ways of the past: how 
much easier it was to care for the 
dying when death was inevitable and 
came as relief to both patient and doc- 
tor. But older doctors come to ICUs 
only as patients or visitors; they do not 
contribute to bridging the age and cul- 
tural voids that make talk of last days 
so difficult in our city hospitals. 

It is the young who confi-ont sor- 
rowing families to ask for DNR or 
organ donation. Skilled in the latest 
algorithms, they know the right reme- 
dies, but only slowly do those brave 
young folk learn to ask why they do 
what they must. Sometimes they do 
things that once they could not have 
imagined to the elderly, who might 
have been their parents or teachers, or 
to the young with AIDS or trauma, who 
might have been their friends. They 
grow a carapace against emotions 
going in or out, deprived of the mean- 
ing that philosophers, historians, the 
rehgious and even the old might bring. 
Older doctors might not understand 
much of what goes on in modern 
MICUs, but they have learned how 
patients and families feel, and even 

how doctors feel. 

Such considerations get no atten- 
tion at medical conferences; for a resi- 
dent to show emotion in the MICU is to 
confess a softness as shameful as igno- 
rance of the latest medical study. Yet 
when they get the chance to talk of 
death, as in our conference, young and 
old physicians alike turn passionate. 
Conversation about such forbidden 
matters brings catharsis, a welcome 
chance to review the tensions of life, 
what brought them to the profession. 
As they work through their own fears 
of death, doctors and nurses uncover 
their own anxieties about living. In 
coming close to dying, we relearn our 
own pains, and begin to define our 
own lives. That happened at our con- 

Women have taken birth back from 
the doctors through home delivery and 
nurse-midwives. They are right who 
urge that decisions about when and 
where to die be taken back fi-om the 
doctors. In eagerness to fix only the 
physiology, doctors risk the futility of 
aggressive therapy continued beyond 
hope of reasonable benefit. 

For some, a "good death" comes 
when the dying person is fully aware of 
impending death but has time to say 
goodbye to family and to living. In 
India, old people, following ancient 
ways, begin to speak of their gradual 
detachment; talking that way helps 
loosen the bond of life. That is quite 
different from America, where to be 
good, a death must be sudden, in the 
midst of action, in the midst of life. 
Fortunately for Yale, our university 
chaplain, Frederick Streets, agrees that 
a "good death" is i) not alone, 2) com- 
fortable, 3) slow enough for a chance 
to say good bye, and 4) at the end of a 
hall Hfe. 

We in the health professions need 
to stop ignoring death. We must talk 
more about our grief and anger at 
death. We need to contemplate our 

Howard M. Spiro '^7 is professor of medi- 
cine at Yale University School of Medicine 
and director of its Program for 
Humanities in Medicine. A gastroenterol- 
ogist by trade, he is the author and editor 
of several books, among them Empathy 
and the Practice of Medicine. Most 
recently, he is one of the editors o/Facing 
Death: Where Religion, Culture and 
Medicine Meet (Yale University Press, 

Winter 1997 


De Geneesher (''The Doctor'"), Franz 
Hanfstaengl, early 1900s 


Harvard Medical Alumni Bulletin 

Students learn from patients facing death 

My Patients, 
My Self 

by Susan D. Block, J. Andrew Billings, Lynn Peterson 

The room is still with awe and anxiety. 
Thirty students and eight faculty members 
wait quietly as a young woman, dressed iyi 
black, her body pierced with numerous 
rings, takes her place in the empty chair. 
The interview begins. Over the next ^y 
minutes, the young woman talks about 
what it means to her to have AIDS, to be 
facing the end of her life, her worries 
about dying alone, her spirituality, and 
her experiences with doctors. The students 
have met their first "'dying patienf as 
part of a new HMS course on "Living with 
Life-Threatening Illness. " 

In the discussion? after the interview, 
the sttidents and faculty talk about how 
their initial aversion to this woman 
because of her multiple body piercings gave 
way to feelings of sadness, empathy and 
respect as they heard about her struggle to 
live with this teirible disease. They were 
surprised that she could so comfortably 
answer direct questions about her feelings 
about death, and that her disease had "not 
destroyed her but refined her, eliminating 
the superficial. " They were disturbed by. 
stories she told about how callous her physi- 
cian had been about telling her she had 
AIDS, and were inspired by her description 
of the wonderful care she had received 
more recently fi'om her medical team, and 
her gratitude for their competence and 

Patient descriptions and 
student comments liave 
been clianged to preserve 

Three years ago, two Harvard 
medical students, recognizing the 
importance of developing clinical 
competence in caring for terminally ill 
patients, approached us about initiat- 
ing an HMS course on end-of-life care. 
Their request felt like a gift, as we had 
been thinking about starting such a 
course ourselves. We quickly found 
wonderful colleagues in the Division 
of Medical Ethics, Geriatrics and the 
hospice community to work with in 
planning and developing the course. 
We also sought input from several 
patients struggling with a terminal ill- 
ness. Out of this patient, student and 
faculty collaboration — supported by a 
National Cancer Institute Palliative 
Care Education grant on Hospice in 
General Medical Education and 
Primary Care, and with the approval 
of the HMS Curriculum Committee 
and joint sponsorship by the depart- 
ments of Ambulatory Care and 
Prevention, Social Medicine, 
Medicine, and Psychiatry — came a 
course we called Care Near the End of 
Life, which was soon renamed Living 
with Life-Threatening Illness. The 
course began in February 1995 for 18 
students, and expanded to 30 students 
in 1996. 

Living with Life-Threatening 
Illness is aimed at first-, second- and 

Winter 1997 


fourth-year students. The primary 
learning mode is an intensive longitu- 
dinal clinical experience with a patient 
with a life-threatening illness, supple- 
mented by weekly seminars, experien- 
tial exercises, structured learning 
experiences, lectures, readings and 
mentorship to provide students with 
the knowledge, attitudes and skills 
necessary in caring for patients near 
the end of life. 

Each student is assigned to a 
patient with a life-threatening illness. 
Students then follow the patients 
through the course of their illness: 
meeting with them at home, during 
office visits to the physician, and when 
they are hospitalized. In addition to 
developing a relationship with the 
patient, the students meet the patients' 
families or significant others, and dis- 
cover from them what it is like to have 
a loved one so ill. Students learn how 
to address sensitive topics such as 
patients' desires for care at the end of 
life, patients' values about what makes 
life worth living, spirituality and reli- 
gious beliefs, and concerns about how 

their loved ones are dealing with the 
strain of having an ill family member 
or friend. 

Many of the patients are in a hos- 
pice program, and students learn from 
the nurses, social workers and pastoral 
counselors in these programs how the 
clinical team supports a patient and 
family in dying at home and how they 
address physical, psychological, and 
spiritual symptoms and distress. They 
also hear about the value of teamwork 
and how hospice professionals manage 
their own stress and grief. When 
patients die, students attend the fiiner- 
als and wakes, learning about the 
process of grief and bereavement, and 
finding out what it feels like as a young 
physician to come close to, and lose, a 

The interdisciplinary faculty 
includes Andrew Billings, internist, 
former hospice medical director and 
head of the Pahiative Care Service at 
MGH; Susan Block, psychiatrist in the 
Division of Psychiatry at BWH and in 
the Department of Ambulatory Care 
and Prevention at Harvard Pilgrim 

Health Center and HMS; Loring 
Conant, geriatrician at Cambridge 
Hospital and former medical director 
of the Hospice of Cambridge; Ruth 
Fishbach, sociologist in the Division of 
Medical Ethics; Marshall Forstein, 
psychiatrist and AIDS advocate at 
Cambridge Hospital; Daniel 
Goodenough, cell biologist and master 
of the Oliver Wendell Holmes 
Society; and Lynn Peterson, surgeon 
at BWH and HPHC and head of the HMS 
Division of Medical Ethics. 

Two faculty members meet weekly 
with groups of six students throughout 
the course to talk about personal reac- 
tions to death, dying and bereavement, 
the experiences of working with the 
patients and responses to readings. 
They help the students build skills in 
understanding and communicating 
with patients and their families. The 
small group sessions emphasize the 
process of self-reflection and explo- 
ration of the meanings of death. Self- 
disclosure about personal reactions to 
the dying, on the part of students and 
faculty, is encouraged as a mode of 

The Long Walk 

Prior to entering medical 
school Anne Hallward worked 
for two years as a hospital 
chaplain in Washington, D.C. 
During this time she was regu- 
larly called to the trauma cen- 
ter because a patient had died 
and the family was about to 
arrive to get the news. It was 
the job of the on-call chaplain 
to accompany the physician 
(usually an intern) down the 
long corridor to the family 
waiting room and to sit with 
the family while they heard the 
news. Afterward she would 
take the family to see the body 
and to say farewell to their 
loved one. 

That long walk to meet the 
family became familiar to her. 
The physician had never met 
the family before and had to 

give them news of a sudden, 
unexpected death. On many 
occasions the doctors would 
share their enormous anxiety 
with her, sometimes clutching 
her arm and asking her what to 
say. It was apparent that they 
had little preparation for this. 
Unfortunately, this anxiety 
often expressed itself in hur- 
ried information loaded with 
medical jargon, the doctor fre- 
quently failing to introduce 
him/herself or to sit down. 
Both the family and the doctor 
suffered through these encoun- 
ters. Anne arrived at medical 
school curious to see how her 
medical training would prepare 
her for these situations and 
was surprised and disap- 
pointed to find that there was 
no core class in death and 
dying expected of all students. 

At the same time, Joshua 
Hauser, a third-year medical 
student, was part of a suiincal 
team caring for a patient who 
was admitted for a routine her- 
nia repair. This woman, who 
had been healthy all her life, 
was discovered while on the 
operating table to have 
metastatic ovarian cancer. The 
sense of shock, fear and sad- 
ness experienced by this 
patient was tremendous; the 
shock and discomfort amongst 
the team was different, but 
also significant. 

Josh's experience with this 
patient and with several others 
who were nearing the end of 
their lives in the hospital made 
him realize how poorly pre- 
pared he was for this part of 
doctoring. He began exploring 


Harvard Medical Alumni Bulletin 

self-discovery and a route to improv- 
ing clinical interactions. 

Prior to this class, I was never sure 
about how to talk with patients who are 
terminally ill. In fact, I never really knew 
how to talk to anybody about death. I 
always felt uneasy and thought that if I 
brought the subject up, I would alienate 
the perso?! with whom I was speaking. 
[Now I know that] it is a topic that should 
not be feared. Talking about death reveals 
feelings and ideas people have that do not 
normally suiface in everyday conversa- 
tions. . . . 

You have given me invaluable gifs of 
insight, and when I am caring for my own 
patients, especially those who are near the 
end of their lives, you will be there. 

- — student letter to her patient 

In addition, large group sessions 
include patient interviews, ethics case 
discussions, a presentation on hospice 
by a multidisciplinary hospice team, an 
introduction to chronic pain manage- 
ment, a panel of physicians talking 
about how they deal with loss, and 

interviews with bereaved family mem- 
bers. Symptom control and depression 
are emphasized to help students recog- 
nize how these problems affect quality 
of life. Students also visit the intensive 
care units at BWH to contrast end-of- 
life issues in the hospital setting with 
those they see in their patients. 

The course ends with a closing rit- 
ual in which students transform the 
classroom space with flowers, candles, 
music and silence into a place for 
reflection, remembering, and stories 
and poetry by and about patients. 

Our first surprise in developing the 
course was that so many students were 
interested in taking it. We had worried 
about offering a course and no one 
taking it; instead, more students signed 
up than we could accommodate. 
Student interest in the course reas- 
sured us that we were addressing an 
important need. We enlarged the 
course (and the faculty) to accommo- 
date more students in the second year. 

Identifying faculty with expertise in 
the comprehensive care of patients at 
the end of life proved to be a signifi- 

cant challenge. Palliative care, 
although a formally accepted specialty 
in Great Britain and on its way to 
becoming one in Canada, is still not a 
recognized discipline in the United 
States, and few faculty members have 
made this a central focus of their pro- 
fessional work. We are growing a mul- 
tidisciplinary faculty, whom we hope 
can become leaders and mentors, not 
only in this course, but in improving 
the care of the dying and their families 
throughout the Harvard system. 

We had anticipated difficulty in 
identifying and recruiting patients to 
participate in the course because of the 
severity of their illnesses and their 
reluctance to open their lives up to 
strangers in the midst of such a hard 
time. When they were coping with 
life-and-death issues, how could we 
ask them to reach beyond themselves 
and contribute as teachers to the edu- 
cation of future physicians? 

We were amazed and moved to 
find so many patients who were willing 
and, in some cases, even eager to par- 
ticipate. Indeed, they often expressed 

how to develop a course in this 
area, and in the process met a 
patient living with metastatic 
breast cancer who stood up at 
a medical conference and won- 
dered why doctors were not 
being taught more about how 
to communicate about death 
and dying. Josh approached 
her and through many conver- 
sations, her ideas and encour- 
agement became an impetus 
for him to work on this project 
in earnest. 

Through serendipity, we each 
decided to begin by contacting 
Alan Mermann, a chaplain and 
physician who had designed 
such a course at Yale. Through 
him, we learned of our mutual 
interest in creating a course on 
end-of-life care at Harvard. We 

began meeting to plan the kind 
of course we felt would have 
helped us. Next, we made con- 
tact with several faculty mem- 
bers with whom we felt 
comfortable working. Over the 
next several months we met to 
further develop and refine the 

Three central issues evolved 
during the first year, one 
expected and two unexpected. 
As planned, students in the 
course wrestled with questions 
around appropriate bound- 
aries: What is the difference 
between friend and patient? Do 
you really have to distance 
yourself to survive this work? 
How do we remain present and 
connected when these experi- 
ences are so painful? The small 

groups offered a place of sup- 
port to explore these and other 

The second issue was an exten- 
sion of the first: whether to 
continue the relationship with 
the patient after the course 
had ended. After much deliber- 
ation, we and the other faculty 
decided to ask the students to 
terminate the relationship as 
part of the course. We felt that 
it would be an important lesson 
in saying how to say goodbye, 
and in dealing with the issues 
of loss while still receiving 
supervision and group support. 
We knew that it would be a 
painful lesson on the limits of a 
professional relationship, and 
some students rebelled. They 
were concerned about aban- 

doning their patients and 
rightly did not feel this had 
been spelled out in the begin- 
ning. As with all first attempts, 
our learning curve was steep. 
Unexpectedly, we had to wres- 
tle with what to call the course. 
We had planned to call it 
"Care Near the End of Life," 
but when recruiting patients to 
teach the course, some 
patients and faculty were 
thrown by such a direct 
acknowledgment that their 
lives were ending. Many of 
these patients had been 
referred to the course by other 
faculty members and it was 
hard to tell over the phone at 
first contact whether they saw 
themselves as being at the end 
of their lives or not. It was dif- 
ficult to know how direct to be 

Winter 1997 


gratitude for the opportunity to teach 
future physicians how to care for peo- 
ple in situations similar to their own. 
Some described the course as an 
opportunity to leave something of 
themselves behind, as a legacy for 
future generations. Still others said 
that they wanted to participate as a 
tribute to the excellent care they were 
receiving fi-om their own physicians or 
to redress care deficiencies they had 

Many of these patients were very 
near death; indeed, about one-third of 
the patients who participated last year 
died during the course. This year we 
have a waiting list of patients who are 
hoping to become involved when the 
course starts again in February. 

In participating in the course, both 
students and patients were choosing to 
develop a relationship that they knew 
would end in a loss. Students antici- 
pated and worried about what it would 
be like to grow close to a patient and 
his or her family, and lose them. They 
expressed concern about imposing on 
patients at such a difficult time. They 

and where each patient stood 
on the continuums of hope and 

This struggle was mirrored by 
the students who had to listen 
carefully to know how and 
when to bring up the subject of 
dying. Together, as both fac- 
ulty and students, we learned 
about the delicacy of honoring 
hope, respecting denial, and 
supporting the unique way that 
individuals prepare for their 
own deaths. 

Anne Hallward '97 is applying 
for residencies in primary care 
and psycltiatry and Josltua 
Hauser '95 is a medical resi- 
dent at Brigham and Women's 

worried that they would have nothing 
to offer to their patients, that they 
would not know what to say or how to 
convey their compassion and concern, 
of becoming overwhelmed with sad- 
ness about their patient's situation, or 
about a past or anticipated loss in their 
own lives. 

Patients were concerned about 
what it would feel like to talk about 
their experience of being so ill and fac- 
ing death. Some lacked confidence 
that they had anything to teach. 
Others expressed concern that they 
would burden the students with their 

We learned that many students 
who signed up for this course, as is 
true of medical students in general, 
have had significant personal losses. 
Virtually all were struggling to explore 
and understand their own personal 
concerns and fears about death in the 
hopes that this would make them bet- 
ter doctors. We found that students 
used the small-group discussions to 
explore their personal experiences and 
that this activity was essential for 
enabling them to relate well to their 

Any time the thought of death came to 
mind, I quickly changed the subject in my 
mind. But since I have chosen medicine as 
my career, I will be faced with death evety 
day, more than once a day. So I knew that 
it was time for me to start dealing with 
death for my own sake. In addition, it 
would help me relate to my patients and 
may even help them that I have given the 
topic seme deep thought. 

— student essay 

We ask medical students to do 
many emotionally difficult things dur- 
ing their training — to put sharp instru- 
ments into people, to treat psychotic 
and profoundly disturbed people, to 
examine patients' bodies and inquire 
about their sexual functions, to sit with 
and attend to dying patients. In asking 
students to carry out these difficult 
tasks of doctoring, we have a responsi- 
bility as educators to prepare them. 

Most medical school curricula pro- 
vide few opportimities for students to 
learn about working with the dying, 
yet all physicians participate in the 
care of dying patients. Indeed, death is 
a shadow over most physician/patient 
encounters. Patients commonly worry: 
"How sick am I?" "What do diese 
symptoms mean?" "Could this be can- 
cer?" An understanding about patients' 
experiences and fears of dying, aware- 
ness of the impact of bereavement on 
family members, and appreciation of 
opportunities to help patients and fam- 
ilies live as well as possible while they 
are dying are critical for physicians to 
provide good care to their patients. 

In the clinical years, students are 
thrown into the teaching hospital with 
few opportunities to reflect on and 
address what it means to participate in 
the care of a dying person. Many stud- 
ies have documented serious deficien- 
cies in the care offered to the dying, 
and in physician communication with 
the dying and their families. Hospitals 
are geared towards speciafized and 
high-technology care of episodic ill- 
ness. Students encounter care that they 
often feel is overly aggressive, receive 
littie teaching about end-of-life issues, 
encounter few good role models, and 
witness difficult deaths. Even though 
clinical education is moving towards 
the ambulatory setting, few students 
have exposure to the hospice pro- 
grams, nursing homes and home care 
settings in which many dying patients 
receive care. 

Our course prepares the student to 
care for the dying in several ways. 
First, it gives each student an opportu- 
nity to examine his or her own fears 
and experiences with death so it is not 
so overwhelming and hidden. It pro- 
vides the doctor-in-training with the 
opportunity to develop ongoing and 
deep relationships with patients, and 
to overcome their natural fear of get- 
ting close to death and suffering. Until 
January 1997, when the new primary 
care longitudinal clerkship begins at 
HMS, only our course has required that 
students have an ongoing relationship 


Harvard Medical Alumni Bulletin 

with patients outside the hospital. 

There were many reasons for which I 
decided to take this class. One of them was 
that I wanted to see how knowing that 
one's death is around the comer gives 
soTfieone a different perspective on life. I 
wanted to see whether knowing one's fate 
ahead of time is a gift or a burden. I still 
do not know the answer to this question, 
but I learned many other things. 

— student essay 

Next, students learn what it means 
for patients to live with life-threaten- 
ing illness, and gain a window into the 
concerns, fears and wishes of patients 
confronting serious illness. Since the 
patients who participate in the course 
are living at home, the student learns 
what dying can be like outside the hos- 
pital, in the home setting, where the 
vast majority of patients prefer to 
spend their last days and weeks. The 
student sees the daily burden on the 
family, confronts the issues of access to 
care in the community, and learns 
about resources in the community 

(especially hospice programs). 

In addition, mentors act as role 
models who value and are expert in 
this form of care, helping the student 
develop skills in sitting with suffering 
people and talking with them about 
end-of-life issues. This course provides 
a model for learning how to deal with 
the ethical dilemmas that pervade 
medical practice, since it incorporates 
hands-on experience, basic communi- 
cation skills, thinking critically about 
options, and reflecting on the physi- 
cian's moral obligation. It brings the- 
ory into practice. 

It is comforting to know that by listen- 
ing we may be alleviating a dying 
patient' s psychological pain just as we alle- 
viate physical pain through the use of 
drugs. It reinforces the notion that the role 
of the physician is not just to heal, hit to 
alleviate suffering and to improve the 
quality of life of their patients, for as long 
as that life exists. 

— student journal 

Students also take away valuable 
personal lessons about how to live 
their lives that may put the consuming 
experience of medical school into bet- 
ter perspective: 

/ learned that it is not always correct to 
^^do imto others what you would have done 
to you. " This golden rule was deeply 
ingrained in my upbringing. I believe that 
this is still tnie in general; however, when 
it comes to sustaining or terminating 
someone's life, this rule is no longer applic- 
able. I think what the patient desires 
should be the utmost priority for his/her 
physician, give?! that the patient is well 
infoiT?ied of all the possibilities and conse- 
quences. After all, we are only their care- 
givers and not their care dictators. 

And another reflects: 

Ultimately, although it's not very 
definitive or easy, the proper approach for 
a doctor/patient relationship, with issues of 
death or any other, is to tij and make a 
connection. The connection can be one of 
real fiHe?idship, shared values or simply of 

The Last Lesson 

My patient, Vicky, died last 
Friday. I wanted to share witli 
you how important her partici- 
pation in the class was to her 
and her family. When I went to 
the wake, there was a framed 
letter from Dr. Federman out at 
the funeral home. It was a let- 
ter thanking her for being in 
the course. At her funeral, the 
hospice chaplain spoke about 
her final days, and mentioned 
that she said one of the most 
significant things she had done 
was to be a participant in the 
course. Also, I had written 
Vicky a letter at the end of the 
course thanking her for being 
my teacher. She gave copies of 
the letter to her family, and her 
son read the letter at the 
funeral yesterday. 

I wanted to tell you this for a 
few reasons. First of all, I 
thought you and all the other 
instructors should know what 
an impact this course can have 
on people. I learned so much, 
and it seems that Vicky and 
her family got something won- 
derful from the course too. So, 
thank you. Also, it might help 
other students who take the 
course to know that doing this 
can make a difference. Many 
times last year, we all felt like 
we were burdens on our 
patients. It was, after all, a 
course for us. I did not realize 
how much it meant to Vicky to 
be doing the course. I was 
lucky enough to be able to find 
this out. 

Finally, it reminded me how 
important it is to do "little" 
things for people. The thank- 
you letter I wrote to Vicky 
seemed like a very small thing 
to me. I almost didn't do it, 
thinking that she would know 
how grateful I was. In the end, 
though, it made a huge differ- 
ence to her, to her family and 
to me. I needed that reminder, 
and I think we all do. 

Jennifer Furin '99 

Winter 1997 


duty and care. And I am slightly relieved 
to think that there is probably not o?je best 
way to make that connection; I think my 
patient may have appreciated me less if I 
came to celebrate his continued existence 
more than simply respect who he is and 
what he has already done. That is the 
beauty of medicine: the professional rela- 
tionships formed are intrinsically personal., 
each one unique and each bringing with it 
new potential and risk. 

The patients, too, had very positive 
experiences participating in the course. 
They and their famiHes expressed grat- 
itude for the students' interest and 
concern. They were grateful to have 
the chance to make a meaningful con- 
tribution, even at a time when they felt 
so limited by their illnesses. 

Our experience as teachers in the 
course confirms our sense of the 
importance and value of this kind of 
teaching, and its many positive effects 
on students. The very existence of the 
course conveys the notion that termi- 
nal care is an important, legitimate and 
worthwhile interest in medicine. 

We hope to show students the 
tremendous personal enrichment and 
perspective we have received from 
working with patients and families fac- 
ing death. The course transmits our 
enthusiasm about the contributions we 
can make to patients and families as 
they confront death and loss, and helps 
to build a network of younger col- 
leagues who view care of the dying as a 
core professional commitment. ^ 

Susaji D. Block is HMS assistant professor 
ofpsychiatiy in the Divisiofi of Psychiatry 
at Brigham. and Women ^s Hospital and in 
the Department of Ambiilatoiy Care and 
Prevention at Harvard Pilgrim Health 
Center. J. Andrew Billings '71 is HMS 
assistant clinical professor of medicine at 
MGH and director of the MGH Palliative 
Care Service, hynn Peterson is HMS asso- 
ciate professor ofsurgeiy at BWH and head 
of the Division of Medical Ethics. 

Goes On 

Many years ago I developed my own vision 
of what awaited me on the other side, a 
kind of way of putting my mind at ease 
that it wouldn't be all that bad. 

I envision that when I die I go to a basket- 
ball court where there is a game always 
going on. The special thing about this 
game is that everyone playing suffered 
great physical illness in life at a young 

There is a guy who had been a quad, a 
guy who had had multiple scleroses, and 
there would be guys who had had cancer 
like me. Here now in this place we will all 
be restored to perfect health. Once again I 
would feel my left lung in my chest, and 
the muscles of strong legs. 

Few words are spoken in this place, but 
everyone knows the pain the other suf- 
fered in life. As in life there is a bond 
between the disabled, in death the lessons 
of life still bond. We are a special group of 
people who fought the good fight, over- 
came the impossible, and have found our 
reward in a new life. 


Harvard Medical Alumni Bulletin 




1^JS/^U4^ 0^^^ ^JlZuU, IS]//W^ ■ ^W**-* 

Copyright Elsa Dorfman, 1996; 

Winter 1997 


Der Tod als Freund ("When Death is a 
Friend''), Alfred Rethel, 1911 


Harvard Medical Alumni Bulletin 

/ Heard A Fly Buzz 

by Emily Dickinson 

I heard a Fly buzz — ^when I died — 
The Stillness in the Room 
Was like the Stillness in the Air — 
Between the Heaves of Storm — 

The Eyes around — had wrung them dry — 
And Breaths were gathering firm 
For that last Onset — when the King 
Be witnessed — in the Room — 

I willed my Keepsakes — Signed away 
What portion of me be 
Assignable — and then it was 
There interposed a Fly — 

With Blue — uncertain stumbling Buzz — 
Between the light — and me — 
And then the Windows failed — and then 
I could not see to see — 

Reprinted by permission of the publishers and the 
Trustees of Amherst College from The Complete 
Poems of Emily Dickson, Thomas H. Johnson, ed., 
Cambridge, Mass.: The Belknap Press of Harvard 
University Press, Copyright© 19^1, 1955, i979i 
198^ by the President and Fellows of Harvard 

The Ship Pounding 

by Donald Hall 

Each morning I made my way 
among gangways, elevators, 
and nurses' pods to Jane's room 
to interrogate grave helpers 
who had tended her all night 
like the ship's massive engines 
that kept its propellers turning. 
Week after week, I sat by her bed 
with black coffee and the Globe 
The passengers on this voyage 
wore masks or cannulae 
or dangled devices that dripped 
chemicals into their wrists, 
but I believed that the ship 
travelled to a harbor 
of breakfast, work, and love. 
I wrote: "When the infusions 
are infused entirely, bone 
marrow restored and lymphoblasts 
remitted, I will take my wife, 
as bald as Michael Jordan, 
home to our dog and day." 
Months later these words turn up 
among papers on my desk at home, 
as I hsten to hear Jane call 
for help, or speak in delirium, 
waiting to make the agitated 
drive to Emergency again, 
for re-admission to the huge 
vessel that heaves water month 
after month, without leaving 
port, without moving a knot, 
without arrival or destination, 
its great engines pounding. 

Reprinted by permission; © 1996 Donald 
Hall. Originally in The New Yorker. 
All rights resetted. 

Winter 1997 


w \ 


i - 


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How Denny-Brown 

to Harvard 

by Sid Gil?nan and Joel A. Vilensky 



Harvard Medical Alumni Bulletin 


It was September of 194 i, two 
years after Great Britain had declared 
war on Germany, and three months 
before the United States entered the 
war. James Bryant Conant, president 
of Harvard University and an emissary 
of President Franklin D. Roosevelt, 
traveled to England to meet with 
Winston Churchill and his cabinet to 
discuss the materials that the United 
States was planning to supply to Great 
Britain under the lend-lease program. 
This program, created by the 
Roosevelt administration, provided 
Great Britain with substantial amounts 
of material to assist the war effort 
without directly involving the United 
States in the conflict. 

At the end of the meeting, 
Churchill, expressing his gratitude on 
behalf of the British people, asked if 
there was anything that England could 
do for Conant. Conant's one request 
was that a certain British medical offi- 
cer be released from his military obli- 
gations so that he could begin serving 
as director of Harvard's neurology unit 
at Boston City Hospital, a position 
that the medical officer had been 
unable to begin because of the war. 
Churchill turned to his colleague Lord 
Hankey, paymaster general, and said, 
"Hankey, see to it." That British med- 
ical officer was Derek E. Denny- 

Who was Denny-Brown, and why 
did Harvard want him enough to 
appeal directly to Churchill? The 
answer to that question contains much 
of the foundation of modern American 

Neurology was an acknowledged 
branch of medicine well before the 
turn of the century. During the early 
and middle parts of the 20th century, 
however, many physicians practicing 
neurology needed to provide care for 
patients with psychiatric disorders in 
order to have sufficient case loads, and 
the field included many practitioners 
known as neuropsychiatrists. It was 
only during the post- World War n era 
in the United States that a generation 
of physicians began to practice neurol- 

ogy as a medical specialty separate 
fi-om psychiatry. These neurologists, 
among whom Denny-Brown was a 
leader, transformed neurology into a 
robust, independent area of internal 
medicine, completely separate from 
psychiatry in all respects except for the 
combined specialty boards, the 
American Board of Psychiatry and 

Derek Ernest Denny-Brown, 
known by his friends as "Denny," was 
born in Christchurch, New Zealand 
on June i, 1901. He graduated from 
the medical school of the University of 
Otago in 1924 and became demonstra- 
tor in anatomy for one year. In 1925 
he sailed from New Zealand to 
England to study in Oxford with the 
world-renowned physiologist. Sir 
Charles Sherrington. Denny-BroviOi 
was astonishingly productive during 
this training period in Sherrington's 
laboratory, publishing 14 papers in 
addition to a thesis that resulted in the 
D. Phil, degree. He participated in 
work leading to now classic papers that 
established fundamental views of neu- 
rophysiology, including the concepts 
of the flexor reflex, occlusion and facil- 
itation, the subliminal fringe, and the 
basic differences between the contrac- 
tile properties of "red" and "white" 

After completing his work in 
Sherrington's laboratory, Denny- 
Brown became resident medical officer 
at the National Hospital for Nervous 
Diseases at Queen Square in London 
in 1928. There he met the leading 
senior neurologists of the time, includ- 
ing Gordon Holmes and Kinnier 
Wilson. In 193 1 he was appointed reg- 
istrar to outpatients at the National 
Hospital and then at Guy's Hospital, 
and in 1935 to the consultant staff at 
Queen Square and St. Bartholomew's 

During these years of intense cfini- 
cal training and practice, he continued 
his research, working after hours and 
on weekends. In 1936 he received a 
Rockefeller traveling fellowship to 
work with John Fulton at Yale, where 

Winter 1997 


he gained expertise in experimental 
surgeiy on animals, which allowed him 
to begin developing animal models of 
human posmral and movement disor- 
ders. He returned to England in 1937, 
resumed clinical practice and teaching 
at Queen Square, and published stud- 
ies on human fibrillation, fasciculation 
and myotonia. 

In 1925, the same year Denny- 
Brown sailed from New Zealand to 
England, Harvard Medical School 
received a substantial grant from the 

Winston Churchill and James Bryant Conant 

Rockefeller Foundation to "establish 
an academic department of neurol- 
ogy." The initial plan was to devote 
the upper three floors of a new med- 
ical building at Boston City Hospital 
to the Neurological Unit, which was 
to be equipped with a large number of 
beds, laboratories for research, facili- 
ties for animal experimentation, and 
office space for full-time staff. Harvard 
would provide personnel and support 
the costs of research and teaching, 
whereas Boston City Hospital agreed 

to provide supplies and patient care. 

The medical building was com- 
pleted in 1930, and between 1930 and 
1939 the Neurological Unit flourished 
under the initial direction of Stanley 
Cobb and then Tracy Putnam, who in 
1939 armoimced that he had accepted 
the position of director of the 
Neurological Institute of New York. 
A search committee was established to 
select a new director, with a mandate 
to identify the individual who showed 
the greatest promise of further devel- 
oping the medical and scientific 
aspects of neurology. 

The search committee recom- 
mended Denny-Brown, who with his 
wife, Sylvia, sailed to Boston in August 
1939 to visit the Neurological Unit 
and evaluate the offer from Harvard. 
After interviews with Charles Burwell 
(the dean of the medical school), mem- 
bers of the neurological unit, the 
search committee and Conant, Denny- 
Brown was offered the position and 
accepted it. 

While the Denny-Browns were on 
their return voyage to England, how- 
ever, German troops invaded Poland 
and Great Britain entered World War 
II. Denny-Brown was thereby assigned 
to British military service and dis- 
patched to Oxford to work with 
patients suffering from head injury. He 
wrote to Conant that although he 
knew that Harvard Medical School 
needed a director of the Neurological 
Unit immediately, he could not accept 
the position at that time. Conant 
responded that the position would be 
kept open for him; H. Houston 
Merritt was appointed acting director. 

Following the conversation 
between Conant and Churchill in 
1 941, Denny-Brown was released from 
military service and sailed from 
England to the United States with his 
wife and their two young sons. 
Although they crossed U-boat infested 
waters, they arrived safely in Boston, 
where Denny-Brown assumed the 
directorship of the unit. 

In 1 945 the British army was des- 
perately short of medical officers and 


Harvard Medical Alumni Bulletin 

requested that Denny-Brown resume 
his mihtary service. He was granted a 
leave from Harvard and became a con- 
sulting neurologist in India and 
Burma. He returned to Harvard in 
1946 and was honored with an 
endowed chair, the James Jackson 
Putnam Professorship of Neurology, 
which he held tmtil his retirement in 

At the Neurological Unit, Denny- 
Brown continued the tradition begun 
by Cobb and Putnam of considering 
neurological research to be an integral 
part of the Harvard program. Denny- 
Brown's personal research projects 
made seminal contributions to an 
amazingly large number of subdisci- 
plines of neurology. He published 
original papers on many neurological 
disorders, including cerebrovascular 
disease, subacute necrotizing 
encephalopathy, Wilson's disease, 
myoclonus, head injury, peripheral 
nerve disease, seizure disorders, 
poliomyelitis, multiple sclerosis and 
muscular dystrophy. He also published 
on the physiological basis of a number 
of disturbances of neurological func- 
tion, including motion sickness, spas- 
ticity, disorders resulting from frontal 
and parietal lobe lesions, visual motor 
functions, diseases of the basal ganglia, 
dystonia, and the cerebral control of 

Although Denny-Brown's papers 
are extremely thorough, his points 
were not always stated succinctly. He 
once received a postcard from the 
great British neurologist F.M.R. 
Walshe that read, "Dear Denny, I see 
you have a paper in Brain. When is the 
English version coming out?" Most of 
his written contributions were also 
presented at scientific meetings of the 
leading American and European neu- 
rological societies, where he was 
known as a formidable discussant of 
the scientific presentations of others, 
frequently highly critical and incisive, 
and at times devastatingly frank. 

Denny-Brown became highly influ- 
ential in American neurology, and was 
elected president of the American 

Neurological Association in 1959. He 
not only produced an exceptional vol- 
ume of high-quality experimental and 
clinical research work, but also trained 
a large number of neurologists, many 
of whom entered academic neurology 
and later became departmental chair- 
men. A 1964 review of the 
Neurological Unit revealed that 
almost half of the university depart- 
ments of neurology in the United 
States were chaired by his former 

Denny-Brown directed the 
Harvard Neurological Unit at Boston 
City Hospital with little assistance. He 
personally saw all of the patients 
assigned to the neurology service by 
making clinical rounds twice weekly. 
He trained not only his own residents 
in adult neurology, but also visiting 
fellows, rotating medical residents 
from other services at Boston City 
Hospital and medical students in their 
third year at Harvard Medical School. 
Frequently, distinguished neurologists 
visiting from other cities or countries 
would join his teaching sessions. 

He held a weekly neuropathology 
conference at which one of the neurol- 
ogy residents assigned to neuropathol- 
ogy would write the protocol of two 
deceased patients with neurological 
disorders. After each protocol had 
been presented, a junior and then a 
senior resident were asked to discuss 
the patient, predicting the pathological 
changes that would be seen. Denny- 
Brown then presented his views of the 
case, masterfully formulating the 
anatomical location responsible for the 
clinical disorder, discussing the patho- 
physiology, and predicting the pathol- 
ogy to be seen. 

Following this exercise, the neu- 
ropathologist would extract the 
patient's formalin-fixed brain from a 
jar, examine its gross features, and 
then slice it in coronal sections to dis- 
play the pathological changes. At times 
the neuropathological changes pre- 
dicted by Denny-Brown's impressive 
formulations were not seen, leading to 
the aphorism among his house officers 

that in those cases the brain was 

Denny-Brown was a masterful 
teacher. He demanded strict attention 
to protocol, thorough and searching 
evaluations of every patient seen, and 
careful histories and physical and neu- 
rological examinations. He required 
that house officers evaluating patients 
with visual disorders construct detailed 
charts of the visual fields. Similarly, 
precise charts of the sensory changes 
were required for all patients with sen- 
sory disorders. Denny-Brown could 
engage an audience with scholarly and 
complete discussions of his patients' 
neurological disorders. His discussions 
often began with the basic anatomical 
changes involved, and progressed to 
the type of neuropathology responsi- 
ble for the clinical picture, the patho- 
physiology of the disorder, differential 
diagnosis and means of management. 

Denny-Brown was given to out- 
bursts of anger if house officers trans- 
gressed by presenting faulty 
information, or worse, by admitting 
that the information requested had not 
been obtained. He was intolerant of 
both patients and house officers who 
did not quickly respond to his 
inquiries with direct, courteous and 
accurate replies. His integrity was of 
the highest order, and he had little 
patience for people who did not mea- 
sure up to his high standards. Despite 
his volatile and at times unpredictable 
outbursts of anger, he was capable of 
great tenderness, sympathy and under- 
standing. He had swift and unerring 
judgment in professional matters and 
was an excellent career counselor. 

Denny-Brown was enormously 
indifferent to earning money beyond 
the bare essentials. One day he exam- 
ined two elderly South American 
brothers who had flown to Boston in 
their personal aircraft with their per- 
sonal physician just to see him. When 
the examination was finished they 
asked Denny-Brown his fee. He 
replied, "$25." The physician, who was 
translating as the brothers spoke no 
English, stated, "You mean $2,500." 

Winter 1997 


"No, no, no, $25," said Denny-Brown. 
That was his fee. 

He was also extremely self-reliant. 
Joseph Foley, who worked with 
Denny-Brown at Boston City Hospital 
from 1946 until 1959, recalled that 
one day he was helping Dermy-Brown 
build something, although Foley had 
no idea what it was. It turned out to be 
his own electromyograph. He also 
repaired his equipment at the labora- 
tory and his appliances at home. 
Nevertheless, Foley also recalled that 
Denny-Brown sometimes could not 
figure out how to operate simple 
devices, such as a flashlight. 

The rich legacy that Denny-Brown 
provided stemmed both from his pio- 
neering work at the forefront of basic 
neurological sciences and his commit- 
ment to clinical neurology as an inde- 
pendent discipline. His influence is 
evident in his many trainees, who 
adopted his obsessive attention to 
detail, emphasis on precision in both 
written and spoken communications 
about patients, incisive and logical 
thinking about disease processes, dedi- 
cation to hard work, and a never-end- 
ing sense of excitement about 
neurological disorders and the basic 
functions of the nervous system. 
Neurology lost a great leader when 
Denny-Brown died on August 20, 

As Foley wrote in a memorial to 
Denny-Brown: "His step was lively, 
his movements quick, and his energy 
boundless. He seemed to have no 
trouble changing directions of actions 
or thought, and always gave intense 
concentration to the issue of the 
immediate here and now." 

During his many years of produc- 
tive work at the Neurological Unit and 
later at the New England Regional 
Primate Research Center, Denny- 
Brown made lilms that depicted the 
behavior of experimental animals and 
interesting patients. The results of this 
effort are 220,000 feet of film of ani- 
mals after central nervous system abla- 
tion experiments, and 15,000 feet of 
film of patients with a wide variety of 

neurological disorders. 

We are cataloguing these films and 
the associated records, and resurrect- 
ing his work by making videotape 
copies available. We are compiling the 
patient films into tapes that will be 
usefiil for teaching medical students, 
physical therapists and neurology resi- 
dents about both commonly seen and 
rare neurological disorders. We are 
also assembling his studies of primates 
into a set of tapes that will be usefal 
for neuroscientists interested in view- 
ing the behavior of the animals upon 
which his many fine papers are based. 

We are honored by and proud of 
our association with Denny-Brown. It 
appears that the search committee and 
Conant had the prescience to sense 
greatness in this man and to petition 
all the way to Churchill to capture him 
for Harvard. Harvard, American neu- 
rology and all of his students and col- 
leagues are greatly indebted to this 
foresight. ^ 

Sid Gilman, MD is p?vfessor of neurology 
and chair of the Department of Neurology 
at the University ofMichigatt School of 
Medicine (Ann Arbor). He studied under 
Denny-Brown between 1^60-6'], first as a 
resident., then as a research fellow, and 
finally as an associate. Joel A. Vilensky, 
PhD is professor of anatomy at the 
Indiana University School of Medicine 
(Fort Wayne). He became interested in 
Denny-Brown^s work approximately five 
years ago., and with Gilman has published 
articles describing and using Denny- 
Brown V research collection. This work is 
currently supported by the Natiottal 
Institutes of Health. Gilman and Vilensky 
are currently gathering material to write 
a biography of Denny-Brown, and are 
gratefiil to Mrs. Sylvia Denny-Brown and 
Dr. Joseph Foley for their assistance in this 

Alumni Notes 

1020 John T. Edsall: "I am current- 
ly working on a biographi- 
cal memoir of my friend 
Jeffries Wyman (1901- 
1995) for the National 
Academy of Sciences. He 
was a PhD, not an MD, but 
his work on proteins was 
fundamental, and will help 
the advancement of knowl- 
edge for a long time to 

1933 William R. Hill: "Retired from 
practice of dermatology in 
June 1996." 

1938 Philip V. Harrington: "In 

November 1995, while in 
Israel, I developed an 
obstructive lesion in colon, 
near splenic flexure. Had a 
hemicolectomy, with end- 
to-end anastamosis. I was 
operated on by Dr. Haskel, 
Hadassah Hospital, 
Jerusalem. Good recovery, 
thus far!" 

1 94-3^ Douglas H. Robinson is 

retired and in poor health. 
His first book, The Zeppelin 
in Combat (1963), has been 
printed again for the fifth 

I 943 ^ Christopher T. Bever: 

"Recently promoted to clin- 
ical professor emeritus of 
psychiatry and behavioral 
sciences at George 
Washington University 
School of Medicine." 

Rudolf A. Jaworski: "Still in 
active practice of pedi- 


Harvard Medical Alumni Bulletin 

i' l^v. » ^ / ■ v.- , ■.1. 



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